Your medical record may contain personal information about your health. This information may identify you and relate to your past, present, or future physical or mental health condition and related health care services. This information is called Protected Health Information (PHI). This Notice of Privacy Practices describes how we may use and disclose your PHI in accordance with applicable law. It also describes your rights regarding how you may gain access to and control your PHI. As required by The Health Insurance Portability & Accountability Act (HIPAA), we maintain the privacy of PHI and provide you with notice of our legal duties and privacy practices with respect to PHI. State law may provide additional restrictions on the use and disclosure of certain information such as HIV/AIDS-related information. We reserve the right to change our privacy practices and to make the new changes effective for all protected health information we maintain. Should our privacy practices change, we will post the revised Notice at our office. You may request a copy of the revised Notice at any time by contacting our Privacy Officer. We will also post the revised Notice on our website at This Privacy Notice is effective August 1, 2014.

How we may use and disclose health care information about you:

For Care or Treatment: Your PHI may be used and disclosed to those who are involved in your care for the purpose of providing, coordinating, or managing your services. This includes consultation with clinical supervisors or other team members. Example: If another dentist referred you to us, we may contact that dentist to discuss your care. Likewise, if we refer you to another dentist we may contact that dentist to discuss your care or they may contact us.

For Payment: Your PHI may be used and disclosed to any parties that are involved in payment for your care or treatment. If you pay for your care or treatment completely out of pocket with no use of any insurance, discount program, or reimbursement plan, you may restrict the disclosure of your PHI for payment. Example: Your payer may require copies of your PHI during the course of a medical record request, chart audit or review.

For Business Operations: We may use or disclose, as needed, you PHI in order to support our business activities including, but not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging other business activities. We may also disclose PHI in the course of providing you with appointment reminder or leaving messages on your phone or at your home about questions you asked or test results. Example: Internal quality assessment review.

Required by Law: Under the law, we must make disclosures of your PHI available to you upon your request. In addition, we must make disclosure to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining our compliance with the requirements of the Privacy Rule, if so required.
Without Authorization: Applicable law and ethical standards permit us to disclose information about you without your authorization only in a limited number of other situations. Examples of some of the types of uses and disclosures that may be made without your authorization are those that are:

  • required by Law, such as the mandatory reporting of child abuse or neglect or mandatory government agency audits or investigations,
  • required by Court Order,
  • pursuant to relevant laws and regulations, we may disclose your health information for law enforcement purposes as required or authorized by law, to report criminal activity, or in response to a valid subpoena, court order, warrant, summons, or other similar process,
  • necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. If information is disclosed to prevent or lessen a serious threat it will be disclosed to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.

Verbal Permission: We may use or disclose your information to family members that are directly involved in your receipt of services with your verbal permission.

With Authorization: Uses and disclosures not specifically permitted by applicable law will be made only with your written authorization, which may be revoked except to the extent that we have relied upon it. Your explicit authorization is required to release psychotherapy notes and PHI for the purposes of marketing, subsidized treatment communication and for the sale of such information.

Your rights regarding your PHI

You have the following rights regarding PHI we maintain about you. To exercise any of these rights, please submit your request in writing to our Privacy Officer.

  • Right of Access to Inspect and Copy: You have the right, which may be restricted only in certain circumstances, to inspect and copy PHI that may be used to make decisions about services provided.
  • Right to Amend: If you feel the PHI we have about you is incorrect or incomplete, you may ask us to amend the information although we are not required to agree to the amendment.
  • Right to an Accounting of Disclosures: You have the right to request an accounting of the disclosures that we make of your PHI. We may charge you a reasonable fee if you request more than one accounting in any 12 month period.
  • Right to Request Restriction: You have the right to request a restriction or limitation on the use of disclosure of your PHI for services, payment, or business operations. We are not required to agree to your request, except as set forth above related to disclosures to a payer where you are paying in full by other means.
  • Right to Request Confidential Communication: You have the right to request that we communicate with you about PHI matters in a specified manner (e.g. telephone, email, postal mail, etc.)
  • Right to a copy of the Notice: You have the right to a copy of this notice.
  • Abide by the terms of any Notice in effect.

Website Privacy

Any personal information you provide us with via our website, including your email address, will never be sold or rented to any third party without your express permission. If you provide us with any personal or contact information in order to receive anything from us, we may collect and store that personal data. In some instances, we may partner with a third party to provide services such as newsletters, surveys to improve our services, health or company updates, and in such case, we may need to provide your contact information to said third parties. We will have a business associate agreement with those third parties where they also agree to protect your information.


You will be notified immediately if we receive information that there has been a breach involving your unsecured PHI.


If you believe we have violated your privacy rights, you have the right to file a complaint in writing with our Privacy Officer at Q Dental. If you have any questions or would like additional information, you may contact us at Q Dental Group PC, 2300 Buffalo Road, Suite 300, Rochester, NY 14624 or with the Office of Civil Rights, U.S. Department of Health and Human Services, Jacob Javits Federal Building, 26 Federal Plaza – Suite 3312, New York, NY 10278, Voice Phone (800) 368-1019, Fax (212) 264-3039, TDD (800) 537-7697. There will be no retaliation for filing a complaint.