Notice of Privacy Practices

HIPAA Notice of Privacy Practices

We are committed to your privacy
We understand that information about you and your health is very personal. We strive to protect our patients’ privacy. We are required by law to maintain the privacy of our patients’ protected health information (PHI). We are also required to provide notice of our legal duties and privacy practices with respect to PHI and to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of this Notice and to make a new Notice effective for all PHI we maintain. You can obtain a copy of the new notice at or by contacting the office.

Who this notice applies to
The terms of this Notice apply to University Square Dental Associates. This Notice also applies to the dentists, hygienist, assistants, office staff, volunteers, shadowers, and trainees seeing and treating patients at University Square Dental Associates. This Notice does not apply to non-employed providers in their private offices such as a doctor to whom a patient may be referred.

Uses and disclosures of your protected health inflation that DO NOT require an authorization
For example, dentists, physicians, and other staff members involved with your care will use and disclose your PHI to coordinate your care or to plan a course of treatment for you.

For example, we may disclose information regarding your procedures and treatment to your insurance company to arrange payment for the services provided to you.

Health Care Operations
For example, we may disclose your PHI for billing or interpreter support. We may use your PHI to conduct an evaluation of the treatment and services provided or to review staff performance. We may disclose your PHI for education and training purposes to dentists, residents, technicians, assistants, and others.

 To persons involved in your care
As long as you do not object, or if you provide written permission, we may, based on our professional judgment, disclose your PHI to a family member or other person if they are involved in your care or paying for your care. Similarly, we may also disclose limited PHI to an entity authorized to assist in disaster relief efforts for the purpose of coordinating notification to someone responsible for your care of your general condition or location.

Communicating with you
We will use your PHI to communicate with you about a number of important topics, including information about appointments, your care, treatment options, and other health-related services, and payment for your care.

We may also contact you at the email, phone number, or address that you provide, including via text messages, for these communications. If your contact information changes, it is important that you let us know. Texting and email are not 100% secure. Regarding text messages, please note that message and data rates may apply and you will have the opportunity to opt out.

Business associates
At times, we need to disclose your PHI to persons or organizations who assist us with our payment/billing activities and operations. We require these business associates and their subcontractors to appropriately safeguard your PHI.

Other uses and disclosures
We may be permitted or required by law to make certain other uses and disclosures of your PHI without your authorization. Subject to conditions specified by law, we may release your PHI:

  • For any purpose required by law
  • For public health activities, including required reporting of disease, injury, birth and death, for required public health investigations, and to report adverse events or enable product recalls
  • To government agencies if we suspect child/elder adult abuse or neglect. We may also release your PHI to government agencies if we believe you are a victim of abuse, neglect, or domestic violence
  • To your employer when we have provided screenings and health care at their request for occupational health and safety
  • To a government oversight agency conducting audits, investigations, inspections, and related oversight functions
  • In emergencies, such as to prevent a serious and imminent threat to a person or the public
  • If required by a court or administrative order, subpoena or discovery request
  • For law enforcement purposes, including to law enforcement officials to identify or locate suspects, fugitives, or witnesses, or victims of crime
  • To coroners, medical examiners, and funeral directors
  • If necessary to arrange organ or tissue donation or transplant
  • For national security, intelligence, or protective services activities
  • For purposes related to your workers’ compensation benefits

Uses and disclosures of your protected health information based on a signed authorization
Except as outlined above, we will not use or disclose your PHI for any other purpose unless you have signed a form authorizing the use or disclosure. You may revoke an authorization in writing, except to the extent we have already relied upon it.

In some situations, a signed authorization form is required for uses and disclosures of your PHI, including:

  • Uses and disclosures for marketing purposes
  • As required by privacy law. The confidentiality of substance use disorder and mental health treatment records as well as HIV-related information maintained by us is specifically protected by state and/or federal law and regulations. Generally, we may not disclose such information unless you consent in writing, the disclosure is allowed by a court order, or in other limited, regulated circumstances.

Your rights
Access to your PHI
Generally, you can access and inspect paper or electronic copies of certain PHI that we maintain about you. You may request access to your health information via writing in office. In line with set fees under federal and state law, a copy may be made for an administrative fee.

Amendments to your PHI
You can request amendments, or changes, to certain PHI that we maintain about you that you think may be incorrect or incomplete. All requests for changes must be in writing, signed by you or your representative, and state the reasons for the request. If we decide to make an amendment, we may also notify others who have copies of the information about the change. Note that even if we accept your request, we may not delete any information already documented in your medical record.

Accounting for disclosures of your PHI
In accordance with applicable law, you can ask for an accounting of certain disclosures made by us of your PHI. This request must be in writing and signed by you or your representative. This does not include disclosures made for purposes of treatment, payment, or health care operations or for certain other limited exceptions. An accounting will include disclosures made in the six years prior to the date of a request.

Restrictions on use and disclosure of your PHI
You can request restrictions on certain of our uses and disclosures of your PHI for treatment, payment, or health care operations. We are not required to agree but will attempt to accommodate reasonable requests when appropriate.

Restrictions on disclosures to health plans
You can request a restriction on certain disclosures of your PHI to your health plan. We are only required to honor such requests when services subject to the request are paid in full. Such requests must be made in writing and identify the services to which the restriction will apply.

Confidential communications
You can request that we communicate with you through alternative means or at alternative locations, and we will accommodate reasonable requests.

Breach notification
We are required to notify you in writing of any breach of your unsecured PHI without unreasonable delay and no later than 60 days after we discover the breach.

Paper copy of notice
You can obtain a paper copy of this Notice, even if you agreed to receive an electronic copy. This Notice is available on our website.

Additional Information
If you believe your privacy rights have been violated, you can file a complaint with the Chief Privacy Officer:

Kristen Leong
3901 Market Street, Box 1936
Philadelphia, PA 19104

You can also file a complaint with the Secretary of the U.S. Department of Health and Human Services in Washington, D.C.

A complaint must be made in writing and will not in any way affect the quality of care we provide you.

For further information
If you have questions about this Notice or requests regarding privacy, please contact us at [email protected] or 215-662-1030.

Effective Date
This notice of Privacy Practices is effective July 1, 2023.