Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

Our Legal Duty

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect (01/01/26) and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including the health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

Uses and Disclosures of Health Information

We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment

We may use or disclose your health information to another dentist, physician or other healthcare provider providing treatment to you.

Your Authorization and Consent

In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

Payment

We may use or disclose your health information as necessary for payment purposes. During the normal course of business operations, we may forward information regarding your medical procedures and treatment to your insurance company to arrange payment for the services provided to you. We may also use information to prepare a bill to send to you or to the person responsible for your payment.

Healthcare Operations

We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Persons Involved in Care

We may use or disclose health information to notify or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures.

In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Appointments and Services

We may contact you to provide appointment updates or information about your treatment or other health-related benefits and services that may be of interest to you. You have the right to request, and we will accommodate reasonable requests by you to receive communications regarding your protected health information from us by alternative means or alternative locations.

For example: if you wish appointment reminders to not be left on voice mail or sent to a particular address, we will accommodate reasonable requests. With such a request, you must provide an appropriate alternative address or method of contact. You also have the right to request that we do not send you any future marketing materials, and we will use our best efforts to honor such requests. You must make requests in writing, including your name and address, and send such writing to the Privacy Officer at the address below.

Business Associates

Aspects and components of our services are performed through contracts with outside persons or organizations, such as auditing, accreditation, outcomes data collection, legal services, etc. At times it may be necessary for us to provide your protected health information to one or more of outside people or organization who assist us with our health care operations. In all cases, we require these associations to appropriately safeguard the privacy of your information.

Marketing Health-Related Services

We will not use your health information for marketing communications without your written authorization.

Research

In limited circumstances, we may use and disclose your protected health information for research purposes. In all cases where your specific authorization is not obtained, your privacy will be protected by strict confidentiality requirements applied by an Institutional Review Board which oversees that research or by representations of the researchers that limit their use and disclosure of your information.

Required by Law

We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect

We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security

We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institutions or law enforcement officials having lawful custody of protected health information of inmate or patient under certain circumstances.

Rights That You Have Regarding Your Protected Health Information

Access to Your Protected Health Information

You have the right to copy and/or inspect the protected health information that we retain on your behalf. For protected health information that we maintain in any electronic designated record set, you may request a copy of such health information in a reasonable electronic format, if readily producible. Requests for access must be made in writing and signed by you or your legal representative.

You may obtain a “Patient’s Access to Health Information Form” from the front office person. You will be charged a reasonable copying fee and actual postage and supply costs for your protected health information. If you request additional copies, you will be charged a fee for copying and postage.

Amendments to Your Protected Health Information

You have the right to request in writing that protected health information that we maintain about you be amended or corrected. We are not obliged to make the requested amendments, but we will give each request careful consideration.

All amendment requests must be in writing, signed by you or legal representative, and must state the reasons for the amendment/correction request. If an amendment or correction request is made, we may notify others who work with us if we believe that such notification is necessary. You may obtain an “Amendment Request Form” from the front office person or individual responsible for dental records.

Restrictions on Use and Disclosures of Your Protected Health Information

You have the right to request restrictions on use and disclosures of your protected health information for treatment, payment or healthcare operations. We are not required to agree to most restriction requests but will attempt to accommodate reasonable requests when appropriate.

You do, however, have the right to restrict disclosure of your protected health information to a health plan. If the disclosure is for the purpose of carrying out payment or healthcare operations and is not otherwise required by law, and the protected health information pertains solely to a healthcare item or services of which you, or someone other than the health plan on your behalf, has paid Gateway Dental Columbus LLC in full.

If we agree to any discretionary restrictions, we reserve the right to remove such restrictions as appropriate. We will notify you if we remove a restriction imposed in accordance with this paragraph. You also have the right to withdraw, in writing or orally, any restriction by communication your desire to do so to the individual responsible for dental records.

Right to Notice of Breach

We take very seriously the confidentiality of our patient’s information, and we are required by law to protect the privacy and security of your protected health information through appropriate safeguards. We will notify you in the event of a breach involving or potentially involving your unsecured health information and inform you of what steps you may need to take to protect yourself.

Paper Copy of This Notice

You have the right, even if you have agreed to receive notices electronically, to obtain a paper copy of this Notice. To do so, please submit a request to the Privacy Office at the address below.

Disclosure Accounting

You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Fertility and Reproductive Health Care Information

We will not use or disclose your protected health information related to fertility treatment, reproductive health care, contraception, pregnancy, pregnancy outcomes, or related services for the purpose of investigating or imposing liability on any person for seeking, obtaining, providing, or facilitating lawful reproductive health care. We are prohibited from disclosing such information to law enforcement, courts, or other parties for these purposes unless required by law and accompanied by a valid legal process that meets applicable federal requirements.

Substance Use Disorder (SUD) Information

Health information that identifies you as having or having had a substance use disorder, including diagnosis, treatment, or referral for treatment, is subject to special confidentiality protections under federal law. Such information will not be used or disclosed without your written authorization, except as permitted or required by law. When disclosed as permitted, this information may be used or disclosed by the recipient only as allowed by federal law, and the recipient may be prohibited from redisclosing the information without your authorization.

Questions and Complaints

If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice.

You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Privacy Officer Contact Information

Contact Officer:
Gateway Dental Columbus LLC – Dr. Aaron Strickland

Telephone:
(812) 370-0019

Fax:
(812) 370-0013

Email:
[email protected]

Address:
2380 Merchant Mile, Suite C
Columbus, IN 47201

Initial Date: 01/01/2026
Updated Date: 08/11/2026