Jackson, MI Pediatric Dentistry

   (517) 787-1022   3386 Spring Arbor Road, Suite 2, Jackson, MI 49203

HomeNotice of Privacy Practices

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 under the HIPAA Omnibus Rule of 2013. Please review this notice carefully.

For purposes of this Notice, “us,” “we,” and “our” refer to Jackson Pediatric Dentistry, and “you” or “your” refers to our patients (or their legal representatives as determined by us per state informed consent law). When you receive healthcare services from us, we will obtain access to your medical information (i.e., your health history). We are committed to maintaining the privacy of your health information, and we have implemented numerous procedures to ensure that we do so.

The Federal Health Insurance Portability & Accountability Act of 2013, HIPAA Omnibus Rule (formally HIPAA 1996 & HI TECH of 2004) require us to maintain the confidentiality of all your healthcare records and other identifiable patient health information (PHI) used by or disclosed to us in any form, whether electronic, on paper, or spoken. HIPAA is a Federal Law that gives you significant new rights to understand and control how your health information is used. Federal HIPAA Omnibus Rule and state law provide penalties for covered entities, business associates, and their subcontractors and records owners, respectively, that misuse or improperly disclose PHI.

Starting April 14, 2003, HIPAA requires us to provide you with a Notice of our legal duties and the privacy practices we must follow when you first come into our office for health-care services. If you have any questions about this Notice, please ask to speak to our HIPAA Privacy Officer. Our doctors, clinical staff, employees, Business Associates (outside contractors we hire), subcontractors, and other involved parties follow the policies and procedures outlined in this Notice. If, at this facility, your primary caretaker/doctor is unavailable to assist you (i.e., illness, on-call coverage, vacation, etc.), we may provide you with the name of another healthcare provider outside our practice for you to consult. If we do so, that provider will follow the policies and procedures outlined in this Notice or those established for his or her practice, so long as they substantially conform to those for our practice.


Under the law, we must have your signature on a written, dated Consent Form and/or an Authorization Form of Acknowledgement of this Notice before we use or disclose your PHI for specific purposes as detailed in the rules below. 

Documentation: You will be asked to sign an Authorization / Acknowledgement form when you receive this Notice of Privacy Practices. If you did not sign such a form or need a copy of the one you signed, please contact our Privacy Officer. You may take back or revoke your consent or authorization at any time (unless we already have acted based on it) by submitting our Revocation Form in writing at the address listed below. Your revocation will take effect when we receive it. We cannot give it retroactive effect, so it will not affect any use or disclosure that occurred in our reliance on your Consent or Authorization before revocation (i.e., if, after we provide services to you, you revoke your authorization/acknowledgment to prevent us billing or collecting for those services, your revocation will have no effect because we relied on your authorization/acknowledgment to provide services before you revoked it).

General Rule: If you do not sign our authorization/acknowledgment form or if you revoke it, as a general rule (subject to exceptions described below under “Healthcare Treatment, Payment and Operations Rule” and “Special Rules”), we cannot in any manner use or disclose to anyone (excluding you, but including payers and Business Associates) your PHI or any other information in your medical record. By law, we cannot submit claims to payers under the assignment of benefits without your signature on our authorization/acknowledgment form. You will, however, be able to restrict disclosures to your insurance carrier for services you wish to pay “out of pocket” under the new Omnibus Rule. We will not condition treatment on you signing an authorization/acknowledgment. Still, we may be forced to decline you as a new patient or discontinue you as an active patient if you choose not to sign the authorization/acknowledgment or revoke it.

Healthcare Treatment, Payment, and Operations Rule

With your signed consent, we may use or disclose your PHI in order:

  • To provide you with or coordinate healthcare treatment and services. For example, we may review your health history form to form a diagnosis and treatment plan, consult with other doctors about your care, delegate tasks to ancillary staff, call in prescriptions to your pharmacy, disclose needed information to your family or others so they may assist you with home care, arrange appointments with other healthcare providers, schedule lab work for you, etc.
  • To bill or collect payment from you, an insurance company, a managed-care organization, a health benefits plan, or another third party. For example, we may need to verify your insurance coverage, submit your PHI on claim forms to get reimbursed for our services, obtain pre-treatment estimates or prior authorizations from your health plan, or provide your x-rays because your health plan requires them for payment; Remember, you will be able to restrict disclosures to your insurance carrier for services for which you wish to pay “out of pocket” under this new Omnibus Rule.
  • To run our office, assess the quality of care our patients receive, and provide you with customer service. For example, to improve efficiency and reduce costs associated with missed appointments, we may contact you by telephone, mail, or otherwise remind you of scheduled appointments; we may leave messages with whoever answers your phone or email to contact us (but we will not give out detailed PHI), we may call you by name from the waiting room, we may ask you to put your name on a sign-in sheet, (we will cover your name just after checking you in), we may tell you about or recommend health-related products and complementary or alternative treatments that may interest you, we may review your PHI to evaluate our staff’s performance, or our Privacy Officer may review your records to assist you with complaints. If you prefer that we not contact you with appointment reminders or information about treatment alternatives, health-related products, and services, please notify us in writing at the address listed below. We will not use or disclose your PHI for these purposes.

The HIPAA Omnibus Rule does not require that we provide the above notice regarding Appointment Reminders, Treatment Information, or Health Benefits. Still, we are including these as a courtesy so you understand our business practices concerning your (PHI) protected health information.

Additionally, you should be made aware of these protection laws on your behalf under the new HIPAA Omnibus Rule:

Health Insurance plans that underwrite cannot use or disclose genetic information for underwriting purposes (this excludes specific long-term care plans). Health plans that post their NOPPs on their websites must post these Omnibus Rule changes on their sites by the effective date of the Omnibus Rule and notify you by US Mail by the Omnibus Rules effective date. Plans that do not post their NOPPs on their Websites must provide you information about Omnibus Rule changes within 60 days of these federal revisions.

Psychotherapy Notes maintained by a healthcare provider must state in their NOPPs that they can allow the “use and disclosure” of such notes only with your written authorization.

Special Rules

Notwithstanding anything else contained in this Notice, only under the applicable HIPAA Omnibus Rule and under strictly limited circumstances, we may use or disclose your PHI without your permission, consent, or authorization for the following purposes:

  • When required under federal, state, or local law
  • When necessary in emergencies to prevent a serious threat to your health and safety or the health and safety of other persons
  • When necessary for public health reasons (i.e., prevention or control of disease, injury, or disability, reporting information such as adverse reactions to anesthesia, ineffective or dangerous medications or products, suspected abuse, neglect or exploitation of children, disabled adults, or the elderly, or domestic violence)
  • For federal or state government health-care oversight activities (i.e., civil rights laws, fraud, abuse investigations, audits, inspections, licensure or permitting, government programs, etc.)
  • For judicial and administrative proceedings and law enforcement purposes (i.e., in response to a warrant, subpoena, or court order, by providing PHI to coroners, medical examiners, and funeral directors to locate missing persons, identify deceased persons or determine the cause of death) 
  • For Worker’s Compensation purposes (i.e., we may disclose your PHI if you have claimed health benefits for a work-related injury or illness)
  • For intelligence, counterintelligence, or other national security purposes (i.e., Veterans Affairs, U.S. military command, other government authorities, or foreign military authorities may require us to release PHI about you)
  • For organ and tissue donation (i.e., if you are an organ donor, we may release your PHI to organizations that handle organ, eye, or tissue procurement, donation, and transplantation)
  • For research projects approved by an Institutional Review Board or a privacy board to ensure confidentiality (i.e., if the researcher has access to your PHI because involved in your clinical care, we will ask you to sign an authorization)
  • To create a collection of information that is “de-identified” (i.e., it does not personally identify you by name, distinguishing marks, or otherwise and no longer can be connected to you)
  • To family members, friends, and others, but only if you are present and verbally give permission. We have allowed you to object. If you do not, we reasonably assume, based on our professional judgment and the surrounding circumstances, that you do not object (i.e., you bring someone with you into the operatory or exam room during treatment or into the conference area when we are discussing your PHI); we reasonably infer that it is in your best interest (i.e., to allow someone to pick up your records because they knew you were our patient and you asked them in writing with your signature to do so); or it is an emergency involving you or another person (i.e. your minor child or ward) and, respectively, you cannot consent to your care because you are incapable of doing so or you cannot consent to the other person’s care because, after a reasonable attempt, we have been unable to locate you. In these emergencies, based on our professional judgment and the surrounding circumstances, we may determine that disclosure is in your best interests or that of the other person, in which case we will disclose PHI. Still, only as it pertains to the care being provided will we notify you of the disclosure as soon as possible after the care is completed. As per HIPAA law 164.512(j) (i)… (A) It is necessary to prevent or lessen a serious or imminent threat to the health and safety of a person or the public, and (B) it is to a person or persons reasonably able to prevent or lessen that threat.

Minimum Necessary Rule

Our staff will not use or access your PHI unless it is necessary to do their jobs (i.e., doctors uninvolved in your care will not access your PHI; ancillary clinical staff caring for you will not access your billing information; billing staff will not access your PHI except as needed to complete the claim form for the latest visit; janitorial staff will not access your PHI). Our team members are trained in HIPAA Privacy rules and sign strict Confidentiality Contracts concerning protecting and keeping your PHI private. So do our Business Associates (and their Subcontractors). Know that your PHI is protected several layers deep concerning our business relations. Also, we disclose to others outside our staff only as much of your PHI as is necessary to accomplish the recipient’s lawful purposes. Still, in certain cases, we may use and disclose the entire contents of your medical record:

  • To you (and your legal representatives as stated above) and anyone else you list on a Consent or Authorization to receive a copy of your records
  • To healthcare providers for treatment purposes (i.e., making diagnosis and treatment decisions or agreeing with prior recommendations in the medical record)
  • To the U.S. Department of Health and Human Services (i.e., in connection with a HIPAA complaint)
  • To others as required under federal or state law
  • To our privacy officer and others as necessary to resolve your complaint or accomplish your request under HIPAA (i.e., clerks who copy records need access to your entire medical record)

Under HIPAA law, we presume that requests for disclosure of PHI from another Covered Entity (as defined in HIPAA) are for the minimum necessary amount of PHI to accomplish the requestor’s purpose. Our Privacy Officer will individually review unusual or non-recurring requests for PHI to determine the minimum necessary amount of PHI and disclose only that. For non-routine requests or disclosures, our Privacy Officer will make a minimum necessary determination based on, but not limited to, the following factors:

  • The amount of information being disclosed
  • The number of individuals or entities to whom the information is being disclosed
  • The importance of the use or disclosure
  • The likelihood of further disclosure
  • Whether the same result could be achieved with de-identified information
  • The technology available to protect the confidentiality of the information
  • The cost to implement administrative, technical, and security procedures to protect confidentiality 

Suppose a request from others to disclose your entire medical record is unnecessary. In that case, we will ask the requestor to document why this is needed, retain that documentation, and make it available to you upon request.

Incidental Disclosure Rule

We will take reasonable administrative, technical, and security safeguards to ensure the privacy of your PHI when we use or disclose it (i.e., we shred all paper containing PHI, require employees to speak with privacy precautions when discussing PHI with you, we use computer passwords and change them periodically (i.e. when an employee leaves us), we use firewall and router protection to the federal standard, we back up our PHI data off-site and encrypted to the federal standard, we do not allow unauthorized access to areas where PHI is stored or filed and/or we have any unsupervised business associates sign Business Associate Confidentiality Agreements).

However, suppose there is a breach in protecting your PHI. In that case, we will first follow Federal guidelines to the HIPAA Omnibus Rule Standard to evaluate the breach using the Omnibus Rule, a 4-factor formula for Breach Assessment. Then we will document the situation, retain copies of the situation on file, and report all breaches (other than low probability as prescribed by the Omnibus Rule) to the US Department of Health and Human Services at http://www.hhs.gov/hipaa/for-professionals/breach-notification/breach-reporting/index.html (If this link is broken, for updated link, Google Search: HIPAA Breach Reporting HHS) We will also make proper notification to you and any other parties of significance as required by HIPAA Law.

Business Associate Rule

Business Associates are defined as an entity (non-employee) that, during their work, will directly / indirectly use, transmit, view, transport, hear, interpret, process, or offer PHI for this Facility.

Business Associates and other third parties (if any) that receive your PHI from us will be prohibited from re-disclosing it unless required by law, or you give prior express written consent to the re-disclosure. Nothing in our Business Associate agreement will allow our Business Associate to violate this re-disclosure prohibition. Under the Omnibus Rule, Business Associates will sign a strict confidentiality agreement binding them to keep your PHI protected and report any compromise of such information to us, you, the United States Department of Health and Human Services, and other required entities. Our Business Associates will also follow the Omnibus Rule and have any of their Subcontractors who may directly or indirectly contact your PHI sign Confidentiality Agreements to the Federal Omnibus Standard.

Super-confidential Information Rule

Suppose we have PHI about you regarding communicable diseases, disease testing, alcohol or substance abuse diagnosis and treatment, or psychotherapy and mental health records (super-confidential information under the law). In that case, we will not disclose it under the General or Healthcare Treatment, Payment, and Operations Rules (see above) without your first signing and properly completing our Consent form (i.e., you specifically must initial the type of super-confidential information we are allowed to disclose). Suppose you do not specifically authorize disclosure by initialing the super-confidential information. In that case, we will not disclose it unless authorized under the Special Rules (see above) (i.e., we are legally required to disclose it). Suppose we disclose super-confidential information (either because you have initialed the consent form or the Special Rules authorizing us to do so). In that case, we will comply with state and federal law that requires us to warn the recipient in writing that re-disclosure is prohibited.

Changes to Privacy Policies Rule

We reserve the right to change our privacy practices (by changing the terms of this Notice) at any time as authorized by law. The changes will be effective immediately upon us making them. They will apply to all PHI we create or receive in the future and to all PHI created or received by us in the past (i.e., to PHI about you that we had before the changes took effect). If we make changes, we will post the changed Notice and its effective date in our office and on our website. Also, upon request, you will be given a copy of our current Notice.

Authorization Rule

We will not use or disclose your PHI for any purpose or to anyone other than as stated in the rules above without your signature on our specifically worded, written Authorization / Acknowledgement Form (not a Consent or an Acknowledgement). If we need your authorization, we must obtain it via a specific authorization form, which may be separate from any authorization / Acknowledgment we may have obtained from you. We will not condition your treatment here on whether you sign the Authorization (or not).

Marketing and Fund Raising Rules

Limitations on the disclosure of PHI regarding Remuneration

The disclosure or sale of your PHI without authorization is prohibited. Under the new HIPAA Omnibus Rule, this would exclude disclosures for public health purposes, for treatment/payment for healthcare, for the sale, transfer, merger, or consolidation of all or part of this facility, and for related due diligence, to any of our Business Associates, in connection with the business associate’s performance of activities for this facility, to a patient or beneficiary upon request, and as required by law. In addition, the disclosure of your PHI for research purposes or for any other purpose permitted by HIPAA will not be considered a prohibited disclosure if the only reimbursement received is “a reasonable, cost-based fee” to cover the cost to prepare and transmit your PHI which would be expressly permitted by law. Notably, under the Omnibus Rule, an authorization to disclose PHI must state that the disclosure will result in remuneration to the Covered Entity.

Limitations on the Use of PHI for Paid Marketing

Per Federal and State Laws, we will obtain your written authorization to use or disclose your PHI for marketing purposes (i.e., to use your photo in ads) but not for activities that constitute treatment or healthcare operations. To clarify, Marketing is defined by HIPAA’s Omnibus Rule as “a communication about a product or service that encourages recipients . . . to purchase or use the product or service.” Communication is not considered “marketing” if it is in writing and if we do not receive direct or indirect remuneration from a third party for communicating.

Under the Omnibus Rule, we will obtain your written authorization before using your PHI for making any treatment or healthcare recommendations, should financial remuneration for making the communication be involved from a third party whose product or service we might promote (i.e., businesses offering this facility incentives to promote their products or services to you). This will also apply to our business associates, who may receive such remuneration for making treatment or healthcare recommendations for you.

We must clarify that financial remuneration does not include “in-kind payments” and payments for implementing a disease management program. Any promotional gifts of nominal value are not subject to the authorization requirement.

The Privacy Rule expressly excludes from the definition of “marketing” refill reminders or other communications about a drug or biologic that is currently being prescribed for you, provided that the financial remuneration received by us in exchange for making the communication, if any, is reasonably related to our cost of making the communication. Face-to-face marketing communications, such as sharing a written product brochure or pamphlet with you, are permissible under HIPAA law.

Flexibility on the Use of PHI for Fundraising

Under the HIPAA Omnibus Rule, covered entities were provided more flexibility concerning using PHI for fundraising efforts. However, we will allow you to “opt-out” of receiving future fundraising communications. Simply let us know that you want to “opt-out” of such situations. There will be a statement on your HIPAA Patient Acknowledgement Form where you can choose to “opt-out.” Our commitment to caring for and treating you will not affect your decision to participate or not participate in our fundraising efforts.

Improvements to Requirements for Authorizations Related to Research

Under the HIPAA Omnibus Rule, we may seek authorization to use your PHI for future research. However, we should make apparent what those uses are in detail.


If you received this Notice via email or website, you can get a paper copy anytime by asking our Privacy Officer. Also, you have the following additional rights regarding PHI we maintain about you:

To Inspect and Copy

You have the right to see and get a copy of your PHI, including, but not limited to, medical and billing records, by submitting a written request to our Privacy Officer. Original records will not leave the premises, will be available for inspection only during our regular business hours, and only if our Privacy Officer is always present. You may ask us to give you the copies in a format other than photocopies (and we will do so unless we determine that it is impractical) or ask us to prepare a summary in place of the copies. We may charge you a fee not exceeding state law to recover our costs (including postage, supplies, and staff time as applicable, excluding staff time for search and retrieval) to duplicate or summarize your PHI. We will not condition the release of the copies on summary of payment of your outstanding balance for professional services if you have one). We will comply with Federal Law to provide your PHI electronically within 30 days to Federal specifications when you provide us with a proper written request. A paper copy will also be made available. We will respond to requests promptly, without delay, for legal review or, in less than thirty days if submitted in writing, and in ten business days or less if malpractice litigation or pre-suit production is involved. We may deny your request in certain limited circumstances (i.e., we do not have the PHI, it came from a confidential source, etc.). If we deny your request, you may ask for a review of that decision. If the law requires, we will select a licensed healthcare professional (other than the person who initially denied your request) to review the denial and follow his or her decision.

To Request Amendment / Correction

Suppose the PHI we have about you is incorrect or something important is missing from your records. In that case, you may ask us to amend or correct it (so long as we have it) by submitting a “Request for Amendment / Correction” form to our Privacy Officer. We will act on your request within 30 days from receipt, but we may extend our response time (within the 30 days) no more than once and by no more than 30 days, or as per Federal Law allowances, in which case we will notify you in writing why and when we will be able to respond. If we grant your request, we will let you know within five business days, make the changes by noting (not deleting) what is incorrect or incomplete and adding to it the changed language, and send the changes within five business days to persons you ask us to and persons we know may rely on incorrect or incomplete PHI to your detriment. We may deny your request under certain circumstances (i.e., it is not in writing, it does not give a reason why you want the change, we did not create the PHI you want to be changed (and the entity that did can be contacted), it was compiled for use in litigation, or we determine it is accurate and complete). If we deny your request, we will (in writing within five business days) tell you why and how to file a complaint with us. If you disagree, you may submit a written disagreement with our denial (and we may submit a written rebuttal and give you a copy of it), that you may ask us to disclose your initial request and our denial when we make future disclosure of PHI about your request, and that you may complain to us and the U.S. Department of Health and Human Services.

To an Accounting of Disclosures

You may ask us for a list of those who got your PHI from us by submitting a “Request for Accounting of Disclosures” form. The list will not cover certain disclosures (i.e., PHI given to you, your legal representative, or others for treatment, payment, or health-care-operations purposes). Your request must state in what form you want the list (i.e., paper or electronically) and the period you want us to cover, which may be up to but not more than the last six years. Suppose we maintain your PHI in an electronic health record. In that case, we must provide you with routine disclosures of PHI, including disclosures of treatment, payment, or healthcare operations, for the three years before the date of the request. If you ask us for this list more than once in 12 months, we may charge you a reasonable, cost-based fee to respond, in which case we will tell you the cost before we incur it and let you choose if you want to withdraw or modify your request to avoid the cost.

To Request Restrictions

You may ask us to limit how your PHI is used and disclosed (i.e., in addition to our rules as outlined in this Notice) by submitting a written “Request for Restrictions on Use, Disclosure” form to us (i.e., you may not want us to disclose your surgery to family members or friends involved in paying for our services or providing your home care). If we agree to these additional limitations, we will follow them except in an emergency where we will not have time to check for limitations. Also, in some circumstances, we may be unable to grant your request (i.e., we are required by law to use or disclose your PHI in a manner that you want restricted).

To Request Alternative Communications

You may ask us to communicate with you in a different way or at a different place by submitting a written “Request for Alternative Communication” Form to us. We will not ask you why, and we will accommodate all reasonable requests (which may include sending appointment reminders in closed envelopes rather than by postcards, sending your PHI to a post office box instead of your home address, communicating with you at a telephone number other than your home number). You must tell us the alternative means or location you want us to use and explain to us to our satisfaction how payment will be made if we communicate with you as you request.

To Complain or Get More Information

We will follow our rules as outlined in this Notice. Suppose you want more information or believe your privacy rights have been violated (i.e., you disagree with our decision about inspection/copying, amendment/correction, accounting of disclosures, restrictions, or alternative communications). In that case, we want to make it right. We never will penalize you for filing a complaint. To do so, please file a formal, written complaint within 180 days with:

The U.S. Department of Health & Human Services Office of Civil Rights

200 Independence Ave., S.W., Washington, DC 20201


Or, submit a written Complaint form to us at the following address: 

  • Privacy Officer: Rachel Crouse
  • Practice Name: Jackson Pediatric Dentistry
  • Address: 3386 Spring Arbor Road, Suite 2, Jackson, MI 49203
  • Office Phone: 517-787-1022
  • Office Fax: 517-787-2150
  • Office Email: info@jaxpedsdds.com

You may get your “HIPAA Complaint” form by calling our privacy officer.

Per the original HIPAA enforcement effective April 14, 2003, these privacy practices are undated to Omnibus.

Effective September 23, 2013, the rule will remain in effect until we replace them as specified by federal and/or state law.