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Notice of Privacy Practices for Team Orthodontics P.C.

This Notice Describes How Private Health Information About You May Be Used and Disclosed, and How you may access this information

Our healthcare practice takes patient privacy matters seriously. We work hard to meet and exceed all existing rules and regulations and will work to keep you informed regarding our office policies and your personal rights regarding privacy.We are required by federal and state law to maintain the privacy of your health information. We are also required to give you this NOTICE about our privacy practices, our duties, and your rights concerning your personal health information. We must follow the privacy practices described in this notice while it is in effect. This notice takes effect on April 14, 2003, and will remain in effect until we replace it, at which time we will issue a new Notice to patients indicating a new activation date. You may request a copy of our Notice at anytime, and may request additional copies, as needed by contacting our office

How We Disclose Health Information:

Specialist Referrals:

We use and disclose health information about you for treatment within our practice, for general healthcare operations and payment collection. That means your information is available to our immediate staff, and to other practitioners who we may refer you to for additional or recommended treatment. This includes, but is not limited to, other healthcare specialists such as surgeons, laboratories and the like. We will exercise our judgment in only distributing the minimum necessary information needed when sending health information to any outside Associates.

General Business Operations:

Your information may be reviewed in the course of general healthcare operations for activities such as conduction quality reviews, assessing practioner performance, evaluation of business costs, conducting training programs, licensing, accreditation, and certain certification activities, and other business related evaluations to help us in improving our delivery of healthcare to our patients.

Family, Friends, Personal Representatives and Others:

We may disclose your health information to a family member, friend, or other persons to the extent necessary to help with your healthcare or with payment for your healthcare. You may however, request we not disclose to anyone other than yourself, of which we will abide. An example where we might disclose to a family member or friend might be when someone drives you to the practice and we are reporting on progress and time remaining before completion, or where a family member desires to pick up a prescription or x-rays on your behalf. We will use our professional judgment and experience with common practice when disclosing your health information to others who may be involved in your healthcare and are trying to ascertain your general condition, your current location, or learn of your death.

Marketing Health Related Services:

We will not use your health information for marketing communications without your written authorization. Under federal privacy rules we may send you update information about our practice or healthcare system, send you information regarding programs and products we offer to further enhance your care and treatment, send reminder notices for appointments, and offer small nominal gifts from time to time, such as tooth brushes, which is not considered marketing. We will never provide your name to an outside organization for marketing.

Our Business Associates:

We require all of our Business Associates to sign a contract specifying they too, are strictly following patient privacy rules and regulations. We will act swiftly and decisively if we find and violate provision of their contract.

When the Law Requires Us to Disclose:

We may disclose your health information to government agencies or other, as required by law. Examples of this include, but are not limited to, law enforcement, required state agency reporting, or coroners seeking to confirm identity. Additionally we disclose to military authorities for purposes such as national security.

Abuse and Neglect:

We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or are the victim of possible other crimes. We disclose to the extent necessary to avert further harm to you or others.

Patient Rights

Access to Records:

You have the right to look at copies of your health information, with limited exceptions. You may request photocopies and copies of x-rays. We will use the format you request, unless we are unable to practically do so. You must make your request to access health information in writing to our practice. We can provide you with a form to do this, or you may do it by writing a letter specifying exactly what you want to view. If we provide photocopies, we will charge you a set amount for each page copied. If you wish to receive x-ray duplicates, we will charge you a set fee per film copied. Check with the office for the current fee schedule. If you request and alternate format we will charge you per the expenses we incur to satisfy your request. You may prefer to ask for a summary rather than receive all of the pages in your file. We can prepare a summary depending on what you are seeking to obtain. The fee for summation will vary depending on time to compile. The hourly rate for summation is also on our current fee schedule.

We have up to 30 days (and sometimes longer) to respond, depending on what is required to meet your request. Specifics will be provided upon request.

List of Disclosures:

You have the right to receive a list of instances in which we, or our business associates, disclosed your health information for purposes other than treatment, payment healthcare operations and few other activities as specified by law, for the last six years, but not before April 14, 2003. If you request this list more than once in a 12 month period we will charge you a reasonable cost based fee for responding to the additional requests. Fees will be disclosed prior to action being taken.


You have the right to place additional restrictions on our use of your health information. We are not required to agree to these restrictions, however, if we do agree, we will abide by our agreement, except in certain emergency situations.

Communications to You:

You may request we communicate with you about your health information by alternative means or to alternative locations, when you make the request in writing. You must specify the alternative means or location and provide satisfactory explanation how payments will be made under the alternative means or location.

Amendment of Your Records:

You have the right to request we amend your health information when requested in writing. We may deny your request, however, we will note in your records your request to amend and reason. We cannot delete anything from the formal record but we can add addendums to the record that may be able to meet you amendment request.

Electronic Notice of this Information:

If you received this information electronically, you are entitled to receive this in written hard copy form.

Privacy Contact:

Amy McCallum
4350 E. Ray Road
Phoenix, AZ 85044