NOTICE OF PRIVACY PRACTICES
Amendment February 16, 2026
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
OUR LEGAL DUTY:
We are required by law to protect the privacy of your protected health information. We are also required to provide this notice to you about our privacy practices, our legal duties and your rights concerning your information. We must follow the privacy practices that are disclosed in this notice while it is in effect. This notice takes effect on the date set forth on the date at the top of the page and will remain in effect unless we replace it. We reserve the right at any time to change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We reserve the right to make any change in our privacy practices and the new terms of this notice at any time. If we make a material change to our policy practices, we will provide a revised notice. Any revised notice will be effective for all health information we maintain. The effective date of a revised notice will be noted.
A copy of the current notice will be available in our facility or on our website. You may request a copy of the current notice at any time. We collect and maintain oral, written and electronic information to administer our business and to provide products, services, and information of importance to our patients. We maintain physical, electronic and procedural safeguards in the handling and maintenance of our patients’ information, in accordance with applicable state and federal standards, to protect against risks such as loss, destruction and misuse.
TREATMENT:
We may disclose your medical information, without your approval, to another dentist or healthcare provider working in our facility or otherwise providing you with treatment for the purpose of evaluating your health, diagnosing dental or medical conditions and providing treatment.
PAYMENT:
We provide dental services. Your medical information may be used to seek payment from your insurance plan or from you. For example, your insurance company may request and receive information on dates that you received services at our facility to process your claim.
HEALTH CARE OPERATIONS:
We may use and disclose our medical information, without your prior approval, for health care operations. Health care operations include:
- Without specific written authorization, we are permitted to use and disclose your health care records for the purposes of treatment, payment and health care operations.
- Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. Examples of treatment would include crowns, fillings, teeth cleaning services, etc.
- Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be billing your dental plan for your dental services.
- 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 include a periodic assessment of our documentation protocols, etc.
- We may disclose your medical information to another provider or to your health plan subject to federal privacy protection laws, if the provider or plan has had a relationship with you.
We may release protected health information to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor. We may use and disclose your protected health information when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
We may disclose your protected health information if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities. We may disclose your protected health information to federal officials for intelligence and national security activities authorized by law.
We may disclose your protected health information to correctional institutions or law enforcement HIPAA officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals or the public.
We may release your protected health information for workers' compensation and similar programs. Any other uses and 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.
We will use and disclose your protected health information when we are required to do so by federal, state or local law. We may disclose your protected health information to public health authorities that are authorized by law to collect information, to a health oversight agency for activities authorized by law included but not limited to: response to a court or administrative order, if you are involved in a lawsuit or similar proceeding, response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
We will release your protected health information if requested by a law enforcement official for any circumstance required by law. We may release your protected health information to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information for funeral directors to perform their jobs.
YOUR AUTHORIZATION:
You (or your legal representative) may give us written authorization to use your information or to disclose it to anyone for any purpose. Once you give us authorization to release your medical information, we cannot guarantee that the person to whom the information is provided will not disclose that information. You may revoke your written authorization at any time, except if we have already acted based on your authorization. Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect. Unless you provide us with written authorization, we will not use or disclose your medical information for any purpose other than those described in this notice. We will obtain your authorization prior to using your information for marketing, fundraising purposes or for commercial use. Once authorized, you may opt out of these communications at any time.
FAMILY, FRIENDS AND OTHERS INVOLVED IN YOUR CARE OR PAYMENT FOR CARE:
We may disclose your information to a family, friend or any other person involved in your care or payment for your healthcare. We will disclose only the information that is relevant to that person’s involvement. We may use or disclose your name, location and general condition to notify, or to assist an appropriate public or private agency to locate and notify, a person responsible for your care in appropriate situations, such as a medical emergency or during disaster relief efforts. We will provide you with an opportunity to object to these disclosures, unless you are not present or are incapacitated or it is an emergency or disaster relief situation. In those situations, we will use our professional judgment to determine whether disclosing your information is in the best interest under the circumstances.
HEALTH-RELATED PRODUCTS AND SERVICES:
We may use your medical information to communicate with you about health-related products, benefits, services, and payment for all related.
COMMUNICATION:
We may use or disclose medical information to send you reminders about your dental care, such as appointment reminders via telephone, text, email or US Mail service. By providing your email address, you agree to receive information from our office regarding appointments, information regarding procedures and treatment, and breach notifications as an alternative to US mail. It is the policy of our office to either text or leave a message on the phone number provided as well as email.
SUD TREATMENT INFORMATION:
Substance Use Disorder (SUD) Treatment records have enhanced protections. They cannot be used in legal proceedings without your consent or court order. If the use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the more stringent law.
If we receive or maintain any information about you from a substance use disorder treatment program that is covered by 42 CFR Part 2 through a general consent you provide to the Part 2 Program to use and disclose the Part 2 Program record for purposes of treatment, payment or health care operation, we may disclose your Part 2 Program record for treatment, payment and health care operations purposes as described in this notice.
If we receive or maintain your Part 2 Program record through specific consent you provide to us or another third party, we will use and disclose your Part 2 Program record only as expressly permitted by you in your consent as provided. In no event will we use or disclose your Part 2 Program record, or testimony that describes the information contained in your Part 2 proceedings by any Federal State, or local authority, against you, unless authorized by your consent or the order of a court after it provides you notice of the court order.
Rights regarding your protected health information:
- 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 by 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 to write to remove it.
- The right to request and receive confidential communications of protected health information from us by alternative means.
- The right to access, inspect and copy your protected health information.
- The right to request an amendment to your protected health information by submitting a written request to our privacy officer. Your request does not guarantee an amendment but does guarantee that it will be reviewed and considered.
- The right to receive an accounting of disclosures of protected health information outside of treatment, payment and health care operations.
- The right to obtain a paper copy of this notice from us upon request.
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.
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. Revisions to our Notice of Privacy Practices will be posted on an effective date and you may request a written copy of the Revised Notice from this office. You have the right to file a formal, written complaint with us at the address below, or with the Department of Health & Human Services, Office of Civil Rights, in the event you feel your privacy rights have been violated. We will not retaliate against you for filing a complaint.
For more information about HIPAA or to file a complaint:
Privacy Officer: Traci Ienco
Address: Alsaidi Perio Center, LLC, 6010 W. Maple Rd. Suite #210, West Bloomfield, MI 48322
Phone: 248-487-9990 Fax: 248-487-9991
Email: manager@alsaidiperio.com
The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
877-696-6775 (toll-free)
