Advanced Dental Arts, LLC

HIPAA Notice of Privacy Practices for Personal Health Information
Effective Date: August 13, 2025

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. IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT Privacy Officer, (478) 207-6939.

WHO WILL FOLLOW THIS NOTICE:

This notice applies to all departments, locations, workforce members, and clinicians providing services at Advanced Dental Arts, LLC. These individuals, sites, and locations may share health information with each other or with third-party specialists for treatment, payment, and health care operations as described below.

 

OUR RESPONSIBILITIES:

We are committed to protecting your medical information. We keep records of the care and services you receive to provide quality care and meet legal requirements. This notice applies to those records. We are required by law to maintain the privacy of your Personal Health Information, provide you with an electronic or paper copy of this notice, follow its terms, and notify affected individuals following a breach of unsecured protected health information.

HOW YOUR INFORMATION IS USED AND SHARED

The following are the ways we may use and share your health information as allowed or required by HIPAA:

 

For Treatment:

We may use your health information to treat you and coordinate your care, including sharing with staff and outside providers. We may also share with family or others involved in your care when you agree, do not object, or when allowed by law. If you have a legal guardian or have given someone medical power of attorney, they may act for you regarding your health information. We will verify their authority before doing so. (Example: A provider treating you for an injury may ask another provider about your overall health).

For Payment:

We may use or share your health information to bill and collect payment for the care you receive, including checking coverage or sending information to your health insurance plan about services or procedures you received. (Example: We give information to your health plan so it will pay for your services or approve a prior authorization.)

For Health Care Operations:

We may use or share your health information to run our practice, improve quality, train staff, and contact you when needed. We may also contact you about treatment options or other health-related services or benefits. (Example: We may share information with companies that securely store medical records, process billing, or provide software services to help run our practice.)

For Public Health, Disaster & Safety:

We may share information for public health and safety, including reporting conditions to public health authorities, product recalls, adverse events, suspected abuse or neglect, preventing or reducing serious threats, and working with coroners, medical examiners, or funeral directors. This may include disaster response to inform loved ones, organ and tissue donation requests, approved health research, and preventing serious threats to health or safety such as contagious diseases or warning those at risk.

For Legal, Law Enforcement & Government:

We may share information for judicial or administrative proceedings (e.g., court or administrative orders, subpoenas), for law enforcement purposes, workers’ compensation claims, with health oversight agencies, when required by federal or state law, (including the U.S. Department of Health and Human Services to check HIPAA compliance), and for certain government functions such as military, national security, and presidential protective services.

Protections for Reproductive Health Care Information:

We are committed to protecting your sensitive health information, including information related to reproductive health care, consistent with applicable federal and state laws.

 

Other Uses of Personal Health Information:

We will not use or share your information for purposes not described in this notice unless you give us written permission. This includes most uses of psychotherapy notes, marketing communications, and the sale of health information. If you give permission and later change your mind, you may revoke your authorization in writing at any time. We may not be able to take back information already shared in reliance on your authorization, including when we already acted on it or when your authorization was part of obtaining insurance coverage and the insurer has legal rights to review, contest a claim, or coverage.

 

YOUR RIGHTS

The following are your rights concerning your Personal Health Information:

Right to Inspect and Copy Your Personal Health Information:

You can see and get a copy of most information we maintain about you (such as billing records) in electronic or paper format, or as a summary. We usually provide it within 30 days, but there may be circumstances where we need more time. Your request must be in writing, and we may charge a reasonable, cost-based fee. Some information (e.g., psychotherapy notes, information compiled for legal proceedings) is not available for inspection or copying. In some cases, we may deny a request; if we do, we will tell you why and explain how you may request a review.

Right to Amend Your Personal Health Information:

If you think information is incorrect or incomplete, you can ask us to amend it while it is kept by or for us. Your request must be in writing. We may deny your request in certain cases (e.g., information is accurate and complete; we did not create it and the creator is available; the information is not part of records we maintain or that you could inspect).

Right to an Accounting of Disclosures:

You can ask for a list of certain disclosures we made about you for up to six years (not including some routine disclosures such as treatment, payment, health care operations, lawful reasons, or disclosures made directly to you). This request must be in writing. We provide one list per year at no charge; a reasonable, cost-based fee may apply for additional requests within 12 months.

Right to Request Restrictions:

You can ask us to limit how we use or share information for treatment, payment, or operations, or with people involved in your care. We are not required to agree, except when you pay out-of-pocket in full for a service and ask us not to share that information with your health plan for payment or operations. You must make your request in writing.

Right to Request Confidential Communications:

You can ask us to contact you in a specific way or at a different location (for example, by mail at a different address). We will accommodate reasonable requests. If you prefer not to be contacted by text message, phone, or through a patient portal, you can ask us to use a different method. You must make your request in writing.

Rights in the Case of Fundraising:

We may contact you for fundraising efforts, but you can tell us not to contact you again.

Right to get a Paper Copy of this Notice:

You can ask for a paper copy of this Notice at any time, even if you agreed to receive it electronically. We will provide a paper copy promptly.

Right to File a Complaint:

If you believe your privacy rights have been violated, you may file a complaint with us. If you have questions on how to file a complaint, or want to file a complaint with us, please contact us at:

Advanced Dental Arts, LLC
Attn: Privacy Officer
4705 Northside Dr Ste 100, Macon, GA 31210

(478) 207-6939

All complaints must be submitted in writing. You will not be penalized for filing a complaint. You can also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, 200 Independence Avenue, S.W., Washington, D.C. 20201

1-877-696-6775 | www.hhs.gov/ocr/privacy/hipaa/complaints

 

Changes to this Notice:

We reserve the right to change the terms of this Notice at any time. Any changes will apply to the health information we already have about you, as well as any information we receive in the future. The effective date of this Notice, and any revised version, is shown on the first page of this notice. The updated Notice will be made available. You may request a copy of this Notice at any time.

I consent to the dental procedures deemed necessary or advisable by the dentist for diagnosis and treatment. During treatment, I may undergo procedures in all phases of dentistry including periodontics (gum treatment and surgery), oral surgery, endodontics (root canals), fixed and removable prosthodontics (crowns, bridges, and dentures), implant dentistry, restorative dentistry, temporomandibular disorder treatment, sleep apnea treatment, oral pathology, pediatric dentistry, and radiography.  I understand that I may ask questions about any aspects of my dental care. I understand that no guarantee can be made regarding treatment results, restoration longevity, or prognoses and that any branch of medicine, including dentistry, can involve unanticipated results.

We are required by law to maintain the privacy of your health information and to provide you with this notice of our legal duties and privacy practices. We use your health information for treatment, to obtain payment for treatment, and for administrative purposes. We will not use or disclose your information without your written authorization, except as described in this notice or as required by law.

A full copy of our Privacy Policy is available upon request.

 

Please provide at least 24-hour notice for cancellations and rescheduling. To ensure timely care and minimize wait times, our office requires confirmation for all scheduled appointments. If we do not receive confirmation from you within 24 hours of your appointment, it is our policy to cancel the appointment and offer the time slot to another patient.

The following is an outline of our office payment policies. Please acquaint yourself with them and then sign below to acknowledge your understanding and acceptance of them.

Please feel free to discuss our fees with us at any time. Before any dental treatment begins, the patient and/or responsible party will receive a consultation regarding treatment plan and cost. We attempt to keep our fees at a fair level that reflects the quality of care provided in our office. Prompt payment will enable us to keep our fees lower for everyone; therefore, payment is due at the time services are rendered. For procedures that take multiple appointments to complete, payment may be split up over the number of appointments required, however full payment must be remitted before delivery of final restoration or appliance.

We accept cash, check (returned check fee $30), Visa, MasterCard, and American Express.

As a courtesy to our patients with insurance, we will file your insurance claim for you. Please remember that the contract is between you and your insurance company, and your total balance in our office is always your responsibility. It is also your responsibility to know the coverage benefits of your insurance policy. We are happy to estimate your benefits, but we have no way to guarantee the actual terms of your insurance policy. The insurance payment may not cover the fee charges in the office. Disputes regarding reimbursement or the amount of reimbursement are between you and your insurance carrier.

Account aging begins the day your charges are incurred. Accounts that are ninety days past due will be turned over to a third party collection agency. We dislike doing this and will do so only if all other efforts to collect your unpaid balance have failed. Once an account is turned over to collections, we will ask you to seek the services of another dentist and will no longer take responsibility for your family’s dental care.

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.

I, the undersigned, authorize Advanced Dental Arts to release my dental and medical information to the following person(s). This includes appointment details, diagnoses, treatment plans, billing information, and any other information related to my dental care.

PATIENT ACKNOWLEDGEMENT AND SIGNATURE

I understand that I may revoke this authorization at any time in writing. Revocation does not apply to information already disclosed under this authorization. Information disclosed may be subject to re-disclosure and may no longer be protected under HIPAA.