Revised 11-07-13


John C. G’Sell, D.D.S., M.A.G.D.


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.



This notice describes how your protected health information (PHI) may be used to carry out treatment, payment or health care operation (TPO) and for other purposes that are permitted or required by law.  It also describes your rights to access and control you protected health information.  “Protected health information”- (PTO) is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.




Your protected health information may be used and disclosed by your physician, our staff and others outside of our office that are involved in your care bills, to support the operation of the physician’s practice and any other used required by law.


Treatment:                  We will use and disclose your PHI to provide, coordinated or manage your health care and any related services.  This includes the coordination or management of your health care with a third party.  For example, we would disclose your PHI as necessary to a home health agency that provides care to you.  Your PHI may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. Your PHI may be emailed to you in a communication using the email address you have provided, unless you state otherwise.  You are not required to provide an email address. If you choose not to have your PHI and sensitive treatment and payment information emailed, you may state this. Otherwise, the email provided is assumed to be secure for your PHI.

Payment:                     Your PHI will be used as needed to obtain payment for your health care services.  This includes release of your PHI to an insurance company, third party payer, credit agency or collection agency as needed to obtain payment for services provided to you. In the event that you pay in full for a dental service out of pocket, you have the right to request that we do not disclose that treatment information for that service to a health plan. This should be done in writing.

Healthcare Operations:          We may disclose as deemed necessary, your PHI in order to support the business activities of your physician’s practice. These activities include, but are not limited to:  quality assessment activates, employee review activities, referral activities and conducting or arranging for other business activities.  For example, we may disclose your PHI to medical providers and other physicians involved in your current or future treatment.  We may use a sign-in-sheet at the registration desk where you will be asked to sign your name.  We may also call you by name in the reception area when your physician is ready to see you or relate to you by name throughout the office.  We may use or disclose your PHI as necessary to contact you: to discuss an appointment, discuss your treatment or financial obligations.  This may be done by phone, text or email.


We may use or disclose your protected health information in the following situations without your authorization.  These situations include, as required by law:  Public Health Issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal Proceedings, Law enforcement, Coroners, Funeral Directors and Organ Donation Research, Criminal Activity, Military Activity and National Security, Workers Compensation and Inmate requirements.  Under the law, we must make disclosures to you when required by the Section of the Department of Health and Human Services to investigate or determine out compliance with the requirements of Section 164.500.


Other Permitted and Required Uses and Disclosures will be made only with your consent and authorization or opportunity to object unless required by law, which precedes your consent. We will not disclose your PHI for use of fundraising or marketing without your expressed consent.

You may revoke this authorization at any time in writing, except to the extent that your physician or the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.


Your Rights:                Following is a statement of your rights to your protected health information.  You have the right to inspect and copy your protected health information.  Under the federal law, however, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonable anticipation of or use in civil, criminal or distractive action or proceeding and protected health information that is subject to law that prohibits access to protected health information. We are obligated to inform you in the event of a breach of unsecured PHI.


You have the right to request a restriction of your PHI; this means you may ask us not to use or disclose any part of PHI for the purpose of treatment, payment or healthcare operation.  You may also request that any part of your protected health information not be disclose to family members or friends who may be involved in your care or for notification purposes as described in this NOTICE OF PRIVACY PRACTICES.              Your request must state the specific restriction requested and to whom you want the restriction to apply.


Your physician is NOT required to agree to a restriction that you may request.  If the physician believes it is in your best interest to permit use and disclosure of your PHI, your protected health information will not be restricted.  You then have the right to use another healthcare professional.


You have the right to request confidential communications from us by alternative means or at an alternative location.  You have the right to obtain a paper copy of this notice from us, upon request even if you have agreed to accept this notice alternatively- electronically.


You may have the right to have your physician amend your protected health information.  If we deny your request for amendment you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement.  We will provide you with a copy of any such rebuttal.


You have the right to receive an accounting of certain disclosures we have made of any of your protected health information.  We reserve the right to change the terms of this notice and will inform you by mail of any changes.  You then have the right to object or withdraw as provided in this notice.


Complaints:       You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us.  You may file a complaint with us by notifying our privacy contact of your complaint.   WE WILL NOT REALIATE AGAINST YOU FOR FILING COMPLAINT.


This notice was published and becomes effective on/or before June 30, 2013.


We are required by law to maintain the privacy of and provide individuals with this notice of our legal duties and privacy practices with respect to protected health information.  If you have any objections to this form, please ask to speak with our HIPPA Compliance Officer in person or by phone at our office phone number.


Signature below is only acknowledgement that you have received this NOTICE OF OUR PRIVACY PRACTICES.


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Printed name                                                                                 Signature




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