HIPAA NOTICE OF PRIVACY PRACTICES
Effective Date: September 25, 2024

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Scope of Notice
This Notice of Privacy Practices applies to all Protected Health Information (PHI) about you held or transmitted by URBN Dental (“we,” “our,” “us”). PHI includes any individually identifiable health information related to your past, present, or future physical or mental health condition, payment for healthcare, or the provision of care to you. This may include information about your treatment, diagnostic tests and images, and related dental or health information.

Our Responsibilities
We are required by law to maintain the privacy of your Protected Health Information, to provide individuals with notice of our legal duties and privacy practices regarding PHI, and to notify affected individuals following a breach of unsecured PHI. We will follow the privacy practices outlined in this Notice while it is in effect. You may request a copy of our Notice at any time. For more information about our privacy practices or to obtain additional copies of this Notice, please contact us using the information provided at the end of this Notice.

Uses and Disclosures of Protected Health Information
Your Protected Health Information may be used and disclosed by our office staff and others involved in your care and treatment for the purposes of providing health care services, processing payments, and supporting the operations of our practice, as well as for other purposes required by law.

Treatment
We may use and disclose your PHI to provide, coordinate, or manage your health care and any related services. For example, we may disclose your information to specialists or other healthcare providers involved in your care to ensure you receive the necessary treatment.

Payment
Your PHI will be used as needed to obtain payment for your health care services. For instance, obtaining approval for a treatment may require us to disclose relevant information to your insurance provider.

Healthcare Operations
We may use or disclose your PHI to support the business activities of our practice, such as quality assessment, training programs, and licensing activities. For example, we might share your information with dental students participating in clinical rotations at our office. We may also utilize sign-in sheets or call your name in our waiting room for appointment purposes.

Permitted Disclosures Without Authorization
We may use or disclose your PHI in the following situations without your authorization:

• Required by Law
• Public Health Activities
• Abuse, Neglect, or Domestic Violence
• Health Oversight Activities
• Law Enforcement
• Judicial and Administrative Proceedings
• Serious Threats to Health or Safety
• Research
• Workers’ Compensation
• Coroners, Funeral Directors, and Organ Donation

Your Rights
You have the right to:

• Access Your PHI: Inspect and obtain copies of your PHI, with certain exceptions.
• Request Restrictions: Ask for additional restrictions on the use and disclosure of your PHI. However, we are not required to agree to these requests.
• Request Alternative Communications: Request to receive communications regarding your PHI by alternative means or locations.
• Amend Your PHI: Request amendments to your PHI if you believe it is inaccurate or incomplete. If we deny your request, you have the right to file a statement of disagreement.
• Receive an Accounting of Disclosures: Obtain a list of certain disclosures we have made regarding your PHI.
• Request a Paper Copy of This Notice: Obtain a paper copy of this Notice upon request, even if you have agreed to receive it electronically.

Changes to This Notice
We reserve the right to change our privacy practices and the terms of this Notice at any time, with changes effective for all PHI that we maintain. We will notify you of any material changes by mail and provide a revised Notice upon request.

Complaints
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of Health and Human Services. You may file a complaint with our Privacy Officer using the contact information below. We will not retaliate against you for filing a complaint.

Contact Information
Questions about our HIPAA Notice of Privacy Practices should be addressed to:

URBN Dental 

2400 Mid Ln #350, Houston, TX 77027

Email: operations@urbndental.com

Phone: (281) 671-7932     Fax: (281) 516-8296