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Fairbury Dental Associates
416 4th Street, Fairbury NE
Notice of Privacy Policies effective February 1, 2014.

You have the right to:
• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated


Your Choices
You have some choices in the way that we use and share information as we:
• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds


Our Uses and Disclosures
We may use and share your information as we:
•  Treat you
• Run our organization
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner or funeral director
• Address workers’ compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions
Your Rights
When it comes to your health information, you have certain rights.

This section explains your rights and some of our
responsibilities to help you.
• You can ask to see or get an electronic or paper copy of your
medical record and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usuallywithin 30 days of your request.

We may charge a reasonable, cost­ based fee.
• You can ask us to correct health information about you that you think is incorrect or incomplete.

Ask us how to do this.
• We may say "no" to your request, but we’ll tell you why in writing within 60 days.
• You can ask us to contact you in a specific way (for example, home or office
phone) or to send mail to a different address.
• We will say "yes" to all reasonable requests.
• You can ask us not to use or share certain health information for treatment,
payment, or our operations. We are not required to agree to your
request, and we may say "no" if it would affect your care.
• If you pay for a service or health care item out­of­pocket in full, you can ask
us not to share that information for the purpose of payment or our
operations with your health insurer. We will say "yes" unless a law
requires us to share that information.
• You can ask for a list (accounting) of the times we’ve shared your health
information for six years prior to the date you ask, who we shared it
with, and why.
• We will include all the disclosures except for those about treatment,
payment, and health care operations, and certain other disclosures
(such as any you asked us to make). We’ll provide one accounting a
year for free but will charge a reasonable, cost­based fee if you ask
for another one within 12 months.
• You can ask for a paper copy of this notice at any time, even if you have
agreed to receive the notice electronically. We will provide you with a
paper copy promptly.
• If you have given someone medical power of attorney or if someone is your
legal guardian, that person can exercise your rights and make
choices about your health information.
• We will make sure the person has this authority and can act for you before
we take any action.
• You can notify us if you feel we have violated your rights by contacting us
using the information on page 1.
• You can file a complaint with the U.S. Department of Health and Human
Services Office for Civil Rights by sending a letter to 200
Independence Avenue, S.W., Washington, D.C. 20201, calling 1­877­
696­6775, or visiting
• We will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you can tell us your choices about what
we share. If you have a clear preference for how we share your information in
the situations described below, talk to us. Tell us what you want us to do, and
we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are
unconscious, we may go ahead and share your information if we believe
it is in your best interest. We may also share your information when
needed to lessen a serious and imminent threat to health or safety.
Our Uses and Disclosures
Treat you
We can use your health information and share it with other professionalswho are treating you.
Example: We may contact your physician about your overall health
Run our organization

We can use and share your health information to run our practice,
improve your care, and contact you when necessary. Example: We use
health information about you to manage your treatment and
Bill for your services
We can use and share your health information to bill and get
payment from health plans or other entities. Example: We give
information about you to your health insurance plan so it will pay
for your services.
How else can we use or share your health information?
We are allowed or required to share your information in other ways –
usually in ways that contribute to the public good, such as public
health and research. We have to meet many conditions in the law
before we can share your information for these purposes. For more
information see:
Help with public health and safety issues
We can share health information about you for certain situations
such as:
• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety
• Research purposes
Comply with the law
We will share information about you if state or federal laws require
it, including with the Department of Health and Human Services if it
wants to see that we’re complying with federal privacy law.
Work with a medical examiner or funeral director
We can share health information with a coroner, medical examiner,
or funeral director when an individual dies.
Address workers’ compensation, law enforcement, and other government requests


We can use or share health information about you:
• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security,
and presidential protective services
Respond to lawsuits and legal actions
We can share health information about you in response to a court
or administrative order, or in response to a subpoena.


Our Responsibilities
• We are required by law to maintain the privacy and security of
your protected health information.
• We will let you know promptly 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 this
notice and give you a copy of it.
• We will not use or share your information other than as described
here unless you tell us we can in writing. If you tell us we can,
you may change your mind at any time. Let us know in writing if
you change your mind.


For more information see:
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will
apply to all information we have about you. The new notice will be
available upon request, in our office.
Jason Grant, DDS. can be reached at 402­729­6177 with questions or
concerns regarding these privacy practices.


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