Notice of Privacy Practices
Your Information. Your Rights. Our Responsibilities.
THIS NOTICE DESCRIBES HOW MEDICAL AND DENTAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
This Notice applies to protected health information (PHI) created or received by Philomena Street PLLC d/b/a Austin Institute of Dental Medicine (AIDM) and by the members of its workforce who participate in your care or in permitted health care operations, including faculty, residents, clinical personnel, and administrative staff.
This HIPAA Notice is separate from AIDM’s general website Privacy Policy, which addresses information collected through the public website that is not PHI. Please do not submit sensitive health information through a general website contact form unless AIDM specifically directs you to a secure method.
At a Glance
| Your Rights | Your Choices | Our Uses & Disclosures |
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Your Rights
When it comes to your health information, you have certain rights. Contact the Privacy Officer to exercise any of these rights.
Get an electronic or paper copy of your record. You may ask to see or obtain an electronic or paper copy of your dental record and other health information we maintain about you. We will generally provide a copy or summary within 30 days. We may charge a reasonable, cost-based fee as permitted by law.
Ask us to correct your record. You may ask us to correct health information that you believe is incorrect or incomplete. We may deny the request in some circumstances, but we will explain the reason in writing, generally within 60 days.
Request confidential communications. You may ask us to contact you in a specific way, such as by phone, text, or email, or to send mail to a different address. We will accommodate reasonable requests.
Ask us to limit what we use or share. You may ask us not to use or share certain information for treatment, payment, or health care operations. We are not always required to agree, and we may deny a request if it could affect your care. If we agree, we may still disclose the information for emergency treatment. If you pay for a service or item out of pocket in full, you may ask us not to share that information with your health plan for payment or health care operations. We will agree unless the law requires disclosure.
Get a list of certain disclosures. You may request an accounting of certain disclosures of your health information made during the six years before your request, including who received the information and why. The accounting will not include disclosures for treatment, payment, health care operations, and certain other disclosures. One accounting in a 12-month period is free; we may charge a reasonable, cost-based fee for additional accountings.
Get a copy of this Notice. You may request a paper copy at any time, even if you agreed to receive this Notice electronically. We will provide it promptly.
Choose someone to act for you. A person with legal authority to act for you, such as a guardian or an agent under a medical power of attorney, may exercise your rights. We will verify that authority before acting.
File a complaint. You may complain if you believe your privacy rights were violated. Contact our Privacy Officer using the information at the end of this Notice. You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights. We will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you may tell us your preferences. Tell us what you want us to do, and we will follow your instructions when the law allows.
Family, friends, and others involved in your care. You may tell us whether to share relevant information with family, close friends, or others involved in your care or payment for your care. You may tell us whether to share information in a disaster-relief situation. If you cannot tell us your preference, we may share information if we believe it is in your best interest or if necessary to lessen a serious and imminent threat to health or safety.
Written authorization is required for certain uses. Unless an exception applies, we will not use or disclose your PHI for the following purposes without your written authorization: most uses and disclosures for marketing purposes; a sale of your PHI; most uses and disclosures of psychotherapy notes, if we maintain any. If you authorize a use or disclosure, you may revoke the authorization in writing at any time. Revocation will not affect actions already taken in reliance on your authorization.
Fundraising. We may contact you about fundraising efforts as permitted by law. You may tell us not to contact you again. If a fundraising communication uses Part 2 substance use disorder information, we will provide clear advance notice and a choice about receiving it, as required by law.
How We Typically Use and Share Your Information
Treatment. We may use your health information and share it with dentists, physicians, specialists, laboratories, pharmacies, faculty, residents, and other professionals involved in your care. Example: We may share radiographs, treatment plans, medication information, or relevant medical history with a specialist or laboratory involved in your care.
Health care operations. We may use and share your information to run the practice, improve the quality and safety of care, coordinate services, train and supervise our workforce, support AIDM’s accredited educational programs, conduct quality assessment and improvement, obtain accreditation or licensure, and contact you when necessary. Example: Faculty may review a resident’s documentation and treatment to supervise care, assess quality, and support the educational program.
Payment. We may use and share your information to bill and obtain payment from you, dental or health plans, and other responsible parties. This may include eligibility checks, prior authorization, claims, appeals, collections, and coordination of benefits. Example: We may provide your dental plan with information about services so it can determine coverage and pay the claim.
Other Permitted or Required Uses and Disclosures
We may use or disclose your information in the following circumstances, subject to the conditions and limits imposed by federal and Texas law.
Public health and safety. We may disclose information for activities such as preventing disease, reporting adverse reactions or product problems, assisting with recalls, reporting suspected abuse, neglect, or domestic violence, and preventing or reducing a serious threat to health or safety.
Research. We may use or disclose information for research when an institutional review board or privacy board has approved the activity, when the information is appropriately de-identified, or when another legal permission applies.
Compliance with law and oversight. We may disclose information when federal or state law requires it, to the U.S. Department of Health and Human Services for HIPAA compliance review, or to health oversight agencies for activities authorized by law.
Organ and tissue donation. We may share information with organ procurement organizations when applicable.
Coroners, medical examiners, and funeral directors. We may disclose information to these professionals when an individual dies and the law permits the disclosure.
Workers’ compensation, law enforcement, and government functions. We may use or disclose information for workers’ compensation claims, lawful law-enforcement purposes, military or national-security functions, and other special government functions authorized by law.
Lawsuits and legal actions. We may disclose information in response to a court or administrative order, subpoena, discovery request, or other lawful process when the applicable legal requirements are met.
Business associates. We may share information with vendors that perform services for us, such as billing, information technology, records storage, analytics, legal, or compliance services. When HIPAA requires it, these vendors must sign agreements requiring them to safeguard PHI and use it only as permitted.
Appointment reminders and care-related communications. We may contact you about appointments, treatment alternatives, follow-up care, benefits, and health-related services that may be of interest to you, as permitted by law and subject to your communication preferences.
Additional Protection for Certain Information
Substance use disorder records. To the extent we receive or maintain substance use disorder patient records protected by 42 C.F.R. Part 2, those records receive additional protection. We will not use or disclose Part 2 records, or testimony describing those records, in a civil, criminal, administrative, or legislative investigation or proceeding against you unless you provide written consent or a court issues the required order and subpoena. Other uses and disclosures of Part 2 records will occur only as permitted by law.
More protective laws. Texas and other federal laws may provide greater privacy protection for certain information, including some mental health, substance use disorder, HIV/AIDS, genetic, and communicable-disease information. When a law is more protective than HIPAA, we will follow the more protective law and obtain your written authorization when required.
Our Responsibilities
We are required by law to maintain the privacy and security of your PHI. We will notify you as required by law if a breach occurs that may have compromised the privacy or security of your information. We must follow the duties and privacy practices described in the Notice currently in effect and provide you with a copy. We will not use or share your information other than as described in this Notice unless you authorize us in writing or the law permits or requires the use or disclosure.
We may change the terms of this Notice. A revised Notice may apply to all PHI we maintain, including information created or received before the revision. The current Notice will be available upon request, posted at our facility, and posted on our website.
Questions, Requests, and Complaints
Contact AIDM’s Privacy Officer to ask questions, exercise your rights, request a copy of this Notice, or make a privacy complaint:
Gloria Estala, HIPAA Privacy Officer
Philomena Street PLLC d/b/a Austin Institute of Dental Medicine
1401 Philomena Street, Austin, TX 78723
Phone: (737) 434-2436
Email: privacy@aidm.org
U.S. Department of Health and Human Services complaint process. You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, by mailing a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201; calling 1-877-696-6775; or filing online at hhs.gov/hipaa/filing-a-complaint. AIDM will not retaliate against you for filing a complaint.
Availability of This Notice
You may request this Notice in paper or electronic form at any time. The current version is available at AIDM’s facility and on AIDM’s website.
