This notice describes how medical information about you may be used and disclosed
and how you can get access to this information. This notice applies to all of the records
of your care generated by More Smiles of Beverly. Please review it carefully.
We reserve the right to change this Notice. We reserve the right to make the revised or
changed Notice effective for medical information we already have about you as well as
any information we receive in the future.
We are required by law to:
• Make sure that medical information that identifies you is kept private.
• Provide you a description of our privacy practices,
• To follow these terms of this Notice, and
• To notify you following a breach of unsecured protected health information, in
accordance with Federal guidelines.
Uses and Disclosures of Health Information
• Treatment: We may use medical information about you to provide you with
medical treatment or services. We may disclose medical information about you to
doctors, nurses, technicians, health care students, or other More Smiles of Beverly
personnel who are involved in taking care of you. We also may disclose medical
information about you to providers or physicians outside of More Smiles of
Beverly who may be involved in your medical care.
• Payment: We may use and disclose medical information about you so that the
treatment and services you receive at the More Smiles of Beverly may be billed
and payment may be collected from you, an insurance company, or a third party.
We may also tell your health plan about a prescribed treatment to obtain prior
approval or to determine whether your plan will cover the treatment.
• Healthcare Operations: We may use and disclose medical information about you
for practice operations. Healthcare operations include quality assessment and
improvement activities, reviewing the competence or qualifications of healthcare
professionals, evaluating practitioner and provider performances, conducting
training programs, accreditation, certification, licensing or credentialing activities.
• Appointment Reminders: We may use and disclose medical information to
contact you as a reminder that you have an appointment for treatment or medical
care at More Smiles of Beverly.
Treatment Alternatives: We may use and disclose medical information to tell you
about or recommend possible treatment options or alternatives that may be of
interest to you.
• Health-Related Benefits and Services: We may use and disclose medical
information to tell you about health-related benefits or services that may be of
interest to you.
• Fundraising Activities: We may use information about you to contact you in an
effort to raise money for More Smiles of Beverly. We will not use your health
information for fundraising activities without your written consent.
• Authorizations Required: We will not use your protected health information for
any purposes not specifically allowed by Federal or State laws or regulations
without your written authorization; this includes uses of your PHI for marketing
or sales activities, including any use or post on any social media site run by More
Smiles of Beverly.
• Emergencies: We may use or disclose your medical information if you need
emergency treatment or if we are required by law to treat you but are unable to
obtain your consent. If this happens, we will try to obtain your consent as soon as
we reasonably can after we treat you.
• Provider Directory: We may include certain limited information about you in the
More Smiles of Beverly directory while you are a patient with us.
• Individuals Involved in Your Care or Payment of Your Care: We may release
medical information about you to a friend or family member who is involved in
your medical care and we may also give information to someone who helps pay
for your care, unless you object in writing and ask us not to provide this
information to specific individuals. In addition, we may disclose medical
information about you to an entity assisting in a disaster relief effort so that your
family can be notified about your condition, status and location.
• Research: Under certain circumstances, we may use and disclose medical
information about you for research purposes, but only when they meet all federal
and state requirements to protect your privacy (such as using only de-identified
data whenever possible).
• As Required By Law: We will disclose medical information about you when
required to do so by federal, state or local law, or to a law enforcement official for
purposes such as providing limited information to locate a missing person or
report a crime, or as permitted by law in connection with a judicial or
administrative proceeding, such as in response to a court order, search warrant, or
• To Avert a Serious Threat to Health or Safety: We may use and disclose medical
information about you when necessary to prevent a serious threat to your health
and safety or the health and safety of the public or another person. Any
disclosure, however, would only be to someone able to help prevent the threat.
Your Rights Regarding Your Medical Information
• Right to Access: You have the right to access, inspect and copy the medical
information that may be used to make decisions about your care, with a few
exceptions. To inspect and copy your medical information, you must submit your
request in writing to More Smiles of Beverly. If you request a copy of the
information, we may charge a fee for the costs of copying, mailing or other
supplies associated with your request. We may deny your request to inspect and
copy medical information in certain very limited circumstances. If you are denied
access to medical information, in some cases, you may request that the denial be
• Right to Amend: You have the right to request an amendment for as long as the
information is kept by or for More Smiles of Beverly. In addition, you must
provide a reason that supports your request. We may deny your request for an
amendment if it is not in writing or does not include a reason to support the
request. In addition, we may deny your request if you ask us to amend
information under certain circumstances.
• Right to an Accounting of Disclosures: You have the right to request an
accounting of disclosures. This is a list of certain disclosures we made of medical
information about you for purposes other than treatment, payment, or healthcare
operations were authorization was not required. Your request must state a time
period which may not be longer than six years and may not include dates before
April 14, 2003. Your request should indicate in what form you want the
accounting (for example, on paper or electronically, if available). The first
accounting you request within a 12 month period will be complimentary. For
additional lists, we may charge you for the costs of providing the list.
• Right to Request Restrictions: You have the right to request a restriction or
limitation on the medical information we use or disclose about you for treatment,
payment, or healthcare operations. You also have the right to request a limit on
the medical information we disclose about you to someone who is involved in
your care or the payment for your care, like a family member or friend. In your
request, you must tell us what information you want to limit, whether you want to
limit our use, disclosure or both, and to whom you want the limits to apply (for
example, disclosures to your spouse). We are not required to agree to these types
of requests. We will not comply with any requests to restrict use or access of
your medical information for treatment purposes. You also have the right to
restrict use and disclosure of your medical information about a service or item for
which you have paid out of pocket, for payment (i.e. health plans) and operational
(but not treatment) purposes, if you have completely paid your bill for this item or
service. We will not accept your request for this type of restriction until you have
completely paid your bill (zero balance) for this item or service. We are not
required to notify other healthcare providers of these restrictions, that is your
responsibility. If we do agree to your request, we will comply with your request
unless the information is needed to provide you emergency treatment.
• Right to Request Confidential Communications: You have the right to request
that we communicate with you about medical matters in a certain way or at a
certain location. We will not ask you the reason for your request. We will
accommodate all reasonable requests. Your request must specify how or where
you wish to be contacted.
• Right to a Paper Copy of This Notice: You have the right to a paper copy of this
Notice. You may ask us to give you a copy of this Notice at any time.
• Right to Revoke Authorization: If you execute any authorization(s) for the use
and disclosure of your protected health information, you have the right to revoke
such authorization(s), except to the extent that action has already been taken in
reliance on such authorization.
To exercise the above rights, please contact the More Smiles of Beverly address listed
at the bottom of this Notice to make your request.
More Smiles of Beverly
2407 W. 104th Street
Chicago, Illinois 60655