Joyful Dental Care

6314 N. Cicero Ave. Chicago, IL 60646
(773) 736-7767

Notice of Privacy Practices


The Health Insurance Portability and Accountability Act of 1996 (*HIPAA*) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.

As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

If you sign a Consent Form, we may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operations.

  • Treatment means providing, coordinating or managing health care and related services by one or more health care providers. An example of this would be a dental examination.
  • Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.
  • Health Care Operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

We may, without prior consent, use or disclose health information to carry out treatment, payment or health care operations in the following circumstances:

  • In emergency treatment situations, if we attempt to obtain such consent as soon as reasonably practicable after the delivery of such treatment;
  • If we are required by law to treat you, and we attempt to obtain such consent but are unable to obtain such consent; OR
  • If we attempt to obtain your consent but are unable to do so due to substantial barriers to communicating with you, and we determine that, in our professional judgement, your consent to receive treatment is clearly inferred from the circumstances.

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to this office.

  • The right to pay in full for a dental procedure and not tell your dental insurance.
  • The right to receive your records in writing or electronically*.
  • The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified as you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
  • The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
  • The right to inspect and copy your protected health information.
  • The right to amend your protected health information.
  • The right to receive an accounting of disclosures of protected health information.
  • The right to obtain a paper copy of this notice from us upon request.
  • The right to opt out of using your or your child's name for fund raising and/or marketing purposes

We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

This notice is effective as of March 26, 2013 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.

You have recourse if you feel that your privacy protections have been violated. You have the right to file a formal, written complaint with us at the address below, or with the Department of Health and Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We may not retaliate against you for filing a complaint.

It is the responsibility of this office to notify you in the event of a breach of an unsecured Protected Health Information (PHI) event.

For more information about HIPAA or to file a complaint:

The U.S. Department of Health and
Human Services Office of Civil Rights
200 Independence Avenue, S. W.
Washington, D.C. 20201
202-619-0257 or 877-696-6775

Please contact us at:
Joyful Dental Care
6314 N. Cicero Ave
Chicago, IL 60646

* If you request this, your email address must be verified, and you will be informed of the possible security risks of emailing sensitive information.

Patient or Guardian Name (Printed):     Date:

Patient or Guardian Signature: ___________________________________
Your signature will be required.