NOTICE OF PRIVACY PRACTICES
SIGNATURE SMILE DESIGNS
JOHN MONSMAN, DMD
Effective Date: January 1, 2026
THIS NOTICE DESCRIBES HOW MEDICAL AND DENTAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
CONTACT INFORMATION
For more information about our privacy practices, questions or concerns, or to obtain additional copies of this Notice, please contact:
Privacy Officer: Matthew A.Spady, HEM, CHPSE
Telephone: 724-473-0462
Fax: n/a
Email: su*****@***********gh.com
Address: P.O. Box 413, Portersville, PA 16051
OUR LEGAL DUTY
We are required by law to maintain the privacy and security of your protected health information ("PHI") in accordance with the Health Insurance Portability and Accountability Act (HIPAA), as amended, and applicable state law.
We are required to provide you with this Notice explaining our legal duties, privacy practices, and your rights regarding your PHI. We must follow the terms of this Notice while it is in effect.
This Notice applies to all PHI we create, receive, maintain, or transmit, whether oral, written, or electronic. We maintain physical, administrative, and technical safeguards to protect your PHI from loss, misuse, unauthorized access, or disclosure.
We reserve the right to change this Notice and our privacy practices at any time, as permitted by law. Any changes will apply to all PHI we maintain, including information created or received before the change. If we make a material change, a revised Notice will be made available in our office, on our website (if applicable), and upon request. The effective date will be listed at the top of the Notice.
USES AND DISCLOSURES OF YOUR HEALTH INFORMATION
Treatment
We may use and disclose your PHI without your authorization to provide, coordinate, or manage your dental and related health care. This may include sharing information with dentists, specialists, laboratories, pharmacies, or other healthcare providers involved in your care.
Payment
We may use and disclose your PHI to obtain payment for dental services provided, including billing insurance plans, benefit determinations, claims management, and collection activities.
Health Care Operations
We may use and disclose your PHI for health care operations, including:
- Quality assessment and improvement activities
- Reviewing provider performance, competence, and qualifications
- Accreditation, licensing, and credentialing activities
- Audits, compliance reviews, and legal services
- Fraud and abuse detection and prevention
- Business planning, management, administration, billing, customer service, and complaint resolution
- Creating de-identified information or limited data sets for health care operations, public health, and research
We may disclose PHI to another healthcare provider or health plan for their health care operations activities when legally permitted and when there is an existing or prior relationship with you.
YOUR AUTHORIZATION
You or your personal representative may give us written authorization to use or disclose your PHI for purposes not described in this Notice. You may revoke your authorization at any time in writing, except to the extent we have already relied on it. We do not use or disclose PHI for marketing, fundraising, or sale of information without your authorization. You may opt out of authorized communications at any time.
INDIVIDUALS INVOLVED IN YOUR CARE
We may share relevant PHI with family members, friends, or others involved in your care or payment for care, unless you object. We may also disclose limited information to assist with disaster relief or emergency notification efforts when appropriate.
APPOINTMENT REMINDERS & HEALTH COMMUNICATIONS
We may contact you by phone, voicemail, text message, email, or mail to provide appointment reminders, treatment information, and practice-related communications. You may request alternative or confidential communication methods.
PLAN SPONSORS
If your dental benefits are provided through an employer-sponsored plan, we may disclose summary health information to the plan sponsor as permitted by law.
PUBLIC HEALTH, LEGAL, AND SAFETY DISCLOSURES
We may use or disclose your PHI without authorization when required or permitted by law, including for:
- Public health reporting and vital statistics
- Reporting abuse, neglect, or domestic violence
- Health oversight activities
- Research, when approved by law
- Judicial and administrative proceedings
- Law enforcement purposes
- Coroners, medical examiners, funeral directors, and organ procurement organizations
- Military, national security, and correctional institution activities
- Workers’ compensation programs
- Preventing a serious and imminent threat to health or safety
If another law provides greater privacy protection than HIPAAÂ we will follow the more stringent law.
SPECIAL PROTECTIONS FOR CERTAIN HEALTH INFORMATION
Substance Use Disorder (SUD) Records
Records related to substance use disorder diagnosis, treatment, or referral are protected by federal law (42 CFR Part 2). These records may not be used or disclosed without your specific written authorization, except as permitted or required by law. Such records are not disclosed for law enforcement, legal proceedings, or administrative actions without a court order or your authorization, except as allowed by law.
Reproductive Health Information
We do not use or disclose reproductive health information for the purpose of investigating or imposing liability related to lawful reproductive health care. Disclosures will only be made as permitted by HIPAA and applicable state law and never for prohibited purposes.
Other Highly Confidential Information
Additional privacy protections may apply to information related to:
- HIV/AIDS
- Mental health treatment
- Genetic testing (GINA)
- Sexually transmitted infections
- Child or adult abuse or neglect, including sexual assault
BUSINESS ASSOCIATES
We may disclose PHI to our business associates who perform services on our behalf. Business associates are required by law and contract to safeguard your information and may only use or disclose it as permitted.
BREACH NOTIFICATION
We may use your contact information to notify you of a breach of your unsecured PHI as required by law.
YOUR RIGHTS
You have the right to:
- Inspect and obtain a copy of your health records
- Request amendments to your health information
- Receive an accounting of certain disclosures
- Obtain a paper or electronic copy of this Notice
- Request restrictions on certain uses or disclosures
- Request confidential communications
- Choose whether to authorize disclosures for marketing or fundraising
- Revoke authorizations at any time (with limited exceptions)
- Opt out of fundraising communications
- File a complaint without fear of retaliation
To exercise these rights, contact our Privacy Officer.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with us or with:
U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue, SW
Washington, DC 20201
Phone: 1-800-368-1019
Website: www.hhs.gov/ocr
We will not retaliate against you for filing a complaint.
This Notice of Privacy Practices is intended to comply with HIPAA, 42 CFR Part 2, and applicable state law as of 2026.
