HIPAA Notice of Privacy Practices
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.
Effective Date: April 22, 2026
Birdwell & Mutlak Dentistry ("we," "us," or "our") is committed to protecting the privacy of your protected health information (PHI). This Notice of Privacy Practices is provided to you under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its implementing regulations (45 CFR § 164.520). It describes how we may use and disclose your PHI to carry out treatment, payment, and health care operations, and for other purposes permitted or required by law. It also describes your rights regarding your PHI.
Our Uses and Disclosures of Your PHI
We may use and disclose your PHI for the following purposes without obtaining your written authorization:
Treatment
We may use and disclose your PHI to provide dental treatment and related services. For example, we may share your information with specialists, laboratories, imaging providers, or other dentists involved in your care to coordinate treatment planning, lab work, referrals, or follow-up care.
Payment
We may use and disclose your PHI to obtain payment for the services we provide. For example, we may submit claims to your dental or medical insurance carrier, to CareCredit, or to another third-party payer, and we may release information required to verify coverage, determine benefits, or process payment.
Health Care Operations
We may use and disclose your PHI for our health care operations — including quality assessment, training, licensing, credentialing, accreditation, business management, and customer service. For example, we may use your information to review the quality of care our team provides or to train dental assistants and hygienists.
Appointment Reminders and Health-Related Communications
We may contact you by phone, text message, email, or mail to remind you of upcoming appointments, to follow up after a procedure, or to share information about treatment alternatives, preventive care, or other health-related services offered by our practice.
Other Uses and Disclosures Permitted or Required by Law
We may use or disclose your PHI without your authorization when required or permitted by law, including: to comply with state or federal reporting requirements; for public health activities (such as reporting disease, injury, or vital statistics); to report suspected abuse, neglect, or domestic violence; for health oversight activities (audits, investigations, licensing); in response to a valid court order, subpoena, or administrative request; to law enforcement under specific legal conditions; to coroners, medical examiners, or funeral directors; for organ, eye, or tissue donation; for approved research purposes under an IRB-approved protocol with appropriate safeguards; to avert a serious and imminent threat to health or safety; for specialized government functions (military, national security, correctional institutions); and for workers' compensation as authorized by law.
Uses and Disclosures That Require Your Written Authorization
The following uses and disclosures of your PHI will be made only with your written authorization:
- Most uses and disclosures of psychotherapy notes (where applicable)
- Uses and disclosures of your PHI for marketing purposes
- Sale of your PHI
- Other uses and disclosures not described in this notice
You may revoke any written authorization at any time, in writing. A revocation does not apply to information we have already used or disclosed in reliance on the authorization.
Your Rights Regarding Your PHI
Right to Inspect and Obtain a Copy
You have the right to inspect and obtain a copy of your PHI in our designated record set, including dental records and billing records, with limited exceptions. Requests must be made in writing. We may charge a reasonable, cost-based fee for copies as allowed by law. We will respond within 30 days of receiving your request.
Right to Request an Amendment
You have the right to request that we amend your PHI if you believe it is incorrect or incomplete. Requests must be made in writing and must include the reason for the amendment. We may deny your request under certain circumstances, but we will provide a written explanation and you will have the right to submit a statement of disagreement.
Right to an Accounting of Disclosures
You have the right to receive a list ("accounting") of certain disclosures of your PHI made by us in the six years prior to your request, excluding disclosures for treatment, payment, health care operations, or disclosures you authorized. The first accounting in any 12-month period is free; additional requests may be subject to a reasonable, cost-based fee.
Right to Request Restrictions
You have the right to request restrictions on certain uses and disclosures of your PHI for treatment, payment, or health care operations. We are not required to agree to your request except in limited circumstances — including a required agreement to restrict disclosure to a health plan if the disclosure is for payment or operations (not treatment), the PHI pertains solely to a health care item or service you paid for out of pocket in full, and the disclosure is not otherwise required by law.
Right to Request Confidential Communications
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location — for example, only by mail to a specific address, or only by phone at work. We will accommodate reasonable requests.
Right to a Paper Copy of This Notice
You have the right to a paper copy of this notice at any time, even if you have agreed to receive it electronically. You may request a paper copy at the front desk or by contacting the Privacy Officer listed below.
Right to Be Notified of a Breach
You have the right to be notified in the event of a breach of your unsecured PHI, as required by federal law.
Right to File a Complaint
You have the right to file a complaint if you believe your privacy rights have been violated. Complaints can be made to our Privacy Officer (contact information below) or to the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you for filing a complaint.
Our Duties
We are required by law to maintain the privacy of your PHI, to provide you with this Notice of our legal duties and privacy practices, and to abide by the terms of the notice currently in effect. We reserve the right to change the terms of this notice and to make the new notice provisions effective for all PHI we maintain. A current copy of this notice will be posted in our practice and on our website.
Contact — Privacy Officer
To request records, file a complaint, or ask questions about your privacy rights or this notice, contact our designated Privacy Officer:
Privacy Officer
Birdwell & Mutlak Dentistry
privacy@birdwelldentist.com
615.550.4620
Complaint to Federal Government
If you believe your privacy rights have been violated, you may also file a complaint with the Secretary of the U.S. Department of Health and Human Services:
Office for Civil Rights, U.S. Department of Health and Human Services
200 Independence Avenue, S.W., Room 509F, HHH Building
Washington, D.C. 20201
1-877-696-6775
hhs.gov/ocr/privacy/hipaa/complaints/
This Notice is provided in accordance with the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations, 45 CFR Parts 160 and 164.