Notice of Privacy Practices

Effective date: July 30, 2026
Applies to: Family Dental Care, 502 Shawnee St, Leavenworth, KS 66048

Our duties

Family Dental Care is required by law to maintain the privacy of your protected health information, to give you this notice of our legal duties and privacy practices, and to notify you following a breach of unsecured protected health information. We are required to follow the terms of the notice currently in effect.

Protected health information means information that identifies you and relates to your dental or general health, the care we provide, or payment for that care. It includes your chart, x-rays and images, treatment plans, appointment history and billing records.

How we use and share your information for treatment, payment and operations

We may use and share your information for these three purposes without your written authorization.

Treatment

We use your information to provide and coordinate your dental care. For example, we review your medical history and medications before an extraction, and we may send your x-rays and treatment notes to an oral surgeon when we refer you for a deeply impacted wisdom tooth.

Payment

We use your information to bill and collect for care. For example, we send your treatment details and diagnostic codes to your dental insurance plan so a claim can be paid, and we may contact your plan in advance to verify your benefits.

Health care operations

We use your information to run the practice and keep quality high. For example, we review records to assess treatment outcomes, train staff, and confirm the care we provide meets professional standards. We may also contact you with appointment reminders or to tell you about treatment alternatives.

Other ways we may use or share your information

Federal law permits or requires us to use or share your information in these situations without your authorization:

• When required by law. Including reporting to state or federal authorities where a law requires it.
• Public health activities. Preventing or controlling disease, reporting adverse events relating to products or medications, and reporting suspected abuse, neglect or domestic violence.
• Health oversight. Audits, investigations, inspections and licensure activity by agencies such as the Kansas Dental Board.
• Judicial and administrative proceedings. In response to a court order, subpoena or other lawful process.
• Law enforcement. To identify or locate a suspect or missing person, to report a crime on our premises, or as otherwise permitted by law.
• Serious threat to health or safety. To prevent or lessen a serious and imminent threat to you or to the public.
• Coroners, medical examiners and funeral directors. To allow them to carry out their duties.
• Organ and tissue donation. To organizations that handle procurement or transplantation.
• Workers' compensation. As authorized by workers' compensation laws.
• Specialized government functions. Including military and veterans activities, national security and protective services, and lawful custody situations.
• Research. Only where an institutional review board or privacy board has approved the use, or where the information has been de-identified.
• Business associates. Companies that perform services for us, such as billing, IT support or record storage. Each is contractually required to safeguard your information.
• People involved in your care. Family, a friend or a personal representative you identify, limited to information relevant to that person's involvement, unless you object.

Substance use disorder records

Some health records that describe treatment for a substance use disorder carry protections stronger than those that apply to the rest of your dental record. If we receive or hold that kind of record, the following applies to it.

• We will not use or share those records in a civil, criminal, administrative or legislative proceeding against you unless you give written consent or a court orders it.
• You may give a single written consent covering future uses and disclosures for treatment, payment and health care operations, and you may revoke that consent at any time in writing, except where we have already acted in reliance on it.
• Anyone who receives those records from us is restricted in passing them on, and a notice of that restriction accompanies any disclosure we make.
• You may complain about a suspected violation of these protections to us or to the U.S. Department of Health and Human Services, and you will not be penalized for complaining.

Uses that require your written permission

Other than the situations described above, we will not use or share your information unless you give us written authorization. In particular, we will always ask your written permission before:

• using or sharing your information for marketing purposes
• selling your information, which we do not do
• sharing any psychotherapy notes, if we ever hold any

If you give authorization, you may revoke it at any time in writing. Revoking it stops future uses and disclosures, but does not undo anything we already did while the authorization was in effect.

If we ever contact you for fundraising, you have the right to tell us not to contact you again for that purpose, and choosing that will not affect your treatment.

Your rights

Get a copy of your dental record

You can ask to see or receive a copy of your record, including in electronic form where we hold it electronically. We will respond within 30 days and may charge a reasonable, cost-based fee. Kansas dental regulations require us to keep your record for at least 10 years after the date of service, so records are generally available for that period.

Ask us to correct your record

If you believe something in your record is wrong or incomplete, you can ask us to amend it. We may decline, and if we do we will explain why in writing and you may submit a statement of disagreement to be kept with the record.

Ask us to limit what we use or share

You can ask us to restrict how we use or share your information. We are not required to agree, with one exception: if you pay for a service in full out of your own pocket and ask us not to tell your insurance plan about it, we must honor that.

Ask us to contact you in a particular way

You can ask us to reach you at a specific phone number or address, or by a particular method. We will accommodate all reasonable requests and will not ask you why.

Get a list of who we shared your information with

You can request an accounting of certain disclosures we made in the six years before your request. The list does not include disclosures for treatment, payment or operations, or ones you authorized. One list in any 12-month period is free.

Get a paper copy of this notice

You can ask for a paper copy at any time, even if you agreed to receive it electronically, and we will give you one promptly.

Be told if your information is breached

We will notify you if a breach occurs that compromises the privacy or security of your information. Kansas law also requires notification where personal information has been or is likely to be misused.

Choose someone to act for you

If you have given someone medical power of attorney, or if someone is your legal guardian, that person can exercise these rights for you. We will verify their authority first.

Complaints

If you believe your privacy rights have been violated, you can complain to us using the contact details below, and we will look into it.

You can also complain to the U.S. Department of Health and Human Services, Office for Civil Rights, 200 Independence Avenue SW, Washington DC 20201, by calling 1-877-696-6775, or at hhs.gov/ocr/privacy/hipaa/complaints. Complaints about the professional conduct of a Kansas dental licensee may be made to the Kansas Dental Board in Topeka.

We will not retaliate against you for making a complaint.

Who to contact

For questions about this notice, to exercise any of the rights above, or to make a complaint, contact our Privacy Officer:

• Family Dental Care, 502 Shawnee St, Leavenworth, KS 66048
• Phone: (913) 651-2115
• Email: familydentallvw@gmail.com

Changes to this notice

We may change this notice, and any change will apply to information we already hold as well as to information we receive in future. The current version is always available at our office and on this page, and it carries the effective date shown at the top.

You may also see our website privacy policy, which covers information collected through this website rather than your dental record, and our terms and conditions.