Effective Date: February 16, 2026
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
CAREFULLY. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.
CONTACT INFORMATION
For more information about our privacy practices, to discuss questions or concerns, or to get
additional copies of this notice, please contact our Privacy Officer.
Name: Becky Burkhart
Telephone: 260-563-7322
Address: 948 Manchester Avenue, Wabash, IN 46992
OUR LEGAL DUTY
We are required by law to protect the privacy of your protected health information (“medical
information”). We are also required to send you this notice about our privacy practices, our
legal duties and your rights concerning your medical information. We must follow the privacy
practices that are described in this notice while it is in effect. This notice takes effect on the date
set forth at the top of this page and will remain in effect unless we replace it. We reserve the
right at any time 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 any
change in our privacy practices and the new terms of our notice applicable to all medical
information we maintain, including medical information we created or received before we made
the change in practices.
We may amend the terms of this notice at any time. If we make a material change in our policy
practices, we will provide to you, the advised notice. Any revised notice will be effective for all
health information we maintain. The effective date of a revised notice will be noted. A copy of
the current notice in effect will be available in our facility and on our website. You may request a
copy of the current notice at any time. We collect and maintain oral, written and electronic
information to administer our business and to provide products, services and information of
importance to our patients. We maintain physical, electronic and procedural safeguards in the
handling and maintenance of our patients’ medica information, in accordance with applicable
state and federal standards, to protect against risks such as loss, destruction and misuse.
USES AND DISCLOSURES OF YOUR MEDICAL INFORMATION
Treatment: We may disclose your medical information, without your prior approval, to another
dentist or healthcare provider working in our facility or otherwise providing you treatment for
the purpose of evaluating your health, diagnosing medical conditions and providing treatment.
For example, your health information may be disclosed to an oral surgeon to determine
whether surgical intervention is needed.
Payment: We provide dental services. Your medical information may be used to seek payment
from your insurance plan or from you. For example, your insurance plan may request and
receive information on dates that you receive services at our facility in order to allow your
employer to verify and process your insurance claim.
Health Care Options: We may use and disclose your medical information, without your prior
approval, for health care operations. Health care operations include:
- healthcare quality assessment and improvement activities;
- reviewing and evaluating dental care provider performance, qualifications and
competence, health care training programs, provider accreditation, certification,
licensing and credentialing activities; - conducting or arranging for medical reviews, audits and legal services, including fraud
and abuse detection and prevention; - business planning, development, management and general administration including
customer service, complaint resolutions and billing, de-identifying medical information,
and creating limited data sets for health care operations, public health activities and
research.
We may disclose your medical information to another dentist or medical provider or to your
health plan subject to federal privacy protection laws, as long as the provider or plan has had a
relationship with you and the medical information is for that provider’s or health plan’s care
quality assessment and improvement activities, competence and qualification evaluation and
review activities, or fraud and abuse detection and prevention.
Your Authorization: You (or your legal personal representative) may give us written
authorization to use your medical information or to disclose it to anyone for any purpose. Once
you give us authorization to release your medical information, we cannot guarantee that the
person to whom the information is provided will not disclose that information. You may take
back or “revoke” your written authorization at any time, except if we have already acted based
on your authorization. Your revocation will not affect any use or disclosure permitted by your
authorization while it was in effect. Unless you give us written authorization, we will not use or
disclose your medical information for any purpose other than those described in this notice. We
will obtain your authorization prior to using your medical information for marketing, fundraising
purposes or for commercial use. Once authorized, you may opt out of these communications at
any time.
Family, Friends and Others Involved in your care or payment for care: We may disclose your
medical information to a family member, friend or any other person involved in your care or
payment for your health care. We will disclose on the medical information that is relevant to the
person’s involvement. We may use or disclose your name, location and general condition to
notify, or to assist an appropriate public or private agency to locate and notify, a person
responsible for your care in appropriate situations, such as a medical emergency or during
disaster relief efforts.
We will provide you with opportunity to reject to these disclosures, unless you are not present
or are incapacitated or it is an emergency or disaster relief situation. In those situations, we will
use our professional judgment to determine whether disclosing your medical information is in
your best interest under the circumstances.
Health-Related Products and Services: We may use your medical information to communicate
with you about health-related products, benefits, services, payment for those products and
services and treatment alternatives.
Reminders: We may use or disclose medical information to send your reminders about your
dental care, such as appointment reminders via US Mail, email and telephone. By providing your
email address to us, you agree that you may receive reminders and breach notifications via
email as a possible alternative to US Mail. It is the policy of our office to leave a message on any
voicemail or answering machine that may be attached to a number that you provide (home, cell
or work). If you prefer that we NOT leave a message to confirm treatment or your
appointments, please do so by marking this circle. O
Plan Sponsors: If your dental insurance coverage is through and employer’s sponsored group
dental plan, we may share summary health information with the plan sponsor.
Public Health and Benefit Activities: We may use and disclose you medical information,
without your permission, when required by law and when authorized by law for the following
kinds of public health and public benefit activities; - for public heath, including to report disease and vital statistics, child abuse, adult abuse,
neglect or domestic violence; - to avert a serious and imminent threat to health or safety;
- for health care oversight, such as activities of state insurance commissioners, licensing
and peer review authorities and fraud prevention agencies; - for research;
- in response to court and administrative orders and other lawful process;
- to law enforcement officials with regard to crime victims and criminal activities;
- to coroners, medical examiners, funeral directors and organ procurement organizations;
- to the military, to federal officials for lawful intelligence, counterintelligence, and
national security activities, and to correctional institutions and law enforcement
regarding persons in lawful custody; and - as authorized by state worker’s compensation laws.
Special protections for SUD records: Substance Use Disorder (SUD) Treatment records have
enhanced protections. They cannot be used in legal proceedings without your consent or court
order.
If a use or disclosure of health information described above in this notice is prohibited or
materially limited by other laws that apply to us, it is our intent to meet the requirements of the
more stringent law.
Business Associates: We may disclose your medical information to our business associates that
perform functions on our behalf or provide us with services if the information is necessary for
such functions or services. Our business associates are required, under contract with us, to
protect the privacy of your information and are not allowed to use or disclose any information
other than as specified in our contract.
Data Breach Notification Purposes: We may use your contact information to provide legally
required notices of unauthorized acquisition, access or disclosure of your health information.
Additional Restrictions on use and disclosure: Certain federal and state laws may require
special privacy protections that restrict the use and disclosure of certain health information,
including highly confidential information about you. “Highly Confidential Information” may
include confidential information under Federal laws governing reproductive rights, alcohol, and
drug abuse information and genetic information as well as state laws that often protect the
following types of information:
- HIV/AIDS;
- Mental Health;
- Genetic Tests (in accordance with GINA 2009);
- Alcohol and drug abuse
- Sexually transmitted diseases and reproductive health information; and
- Child or adult abuse or neglect, including sexual assault
YOUR RIGHTS - You have a right to see and get a copy of your health records.
- You have a right to amend your health information.
- You have a right to ask to get an Accounting of Disclosures of when and why your health
information was shared for certain purposes. - You are entitled to receive a Notice of Privacy Practices that tells you how your health
information may be used and shared. - You may decide if you want to give your Authorization before your health information
may be used and shared for certain purposes, such as marketing. It is the policy of our
office NOT to sell or disclose your information to any outside firms or business partners.
Your information may be used, only within our office, for the purposes of presenting to
you certain products or services which our dentist(s) or staff feel may present a benefit
for you, your oral health or happiness with your smile. If you would like to opt out of
this level of service, you may do so by marking this circle. O - You have the right to receive your information in a confidential manner and restrict
certain communication methods. - You have a right to restrict who receives your information
- You have a right to request an amendment to be made to your health records by
submitting the request in writing to our privacy officer. Your request does not guarantee
the amendment, but does guarantee that it will be reviewed and considered. - If you believe your rights are being denied or your health information is not being
protected, you can:
a. File a complaint with your provider or health insurer
b. File a complaint with the U.S. Government - Right to opt out of fundraising activities. If you would like to opt out of any fundraising
programs that our office may participate in, such as cancer walks, or other fundraising
programs you may do so by marking this circle. O
COMPLAINTS
If you are concerned that we may have violated your privacy rights, or you disagree with a
decision we made about access to your medical information, about amending your medical
information, about restricting our use or disclosure of your medical information, or about
how we communicate with you about you medical information (including a breach notice
communication), you may contact our Privacy Officer to register either a verbal or written
complaint. You may also submit a written complain to the Office of Civil Rights of the United
States Department of Health and Human Services, 200 Independence Avenue, SW, Room
509F, Washington, DC, 20201. You may contact the office for Civil Rights’ hotline at 1-800-
368-1019. We support your right to privacy of your medical information. We will not
retaliate in any way if you choose to file a complaint with us or with the US Department of
Health and Human Services.