Notice of Privacy Practices
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.
This Notice applies to Imagine Medical & Dental Group and its affiliated practices located at 1075 Zonolite Road NE, Atlanta, GA 30306: Imagine Dental, Imagine Orthodontics, and Imagine Gynecology.
We reserve the right to change our privacy practices and the terms of this Notice at any time, as permitted by law. Any revised Notice will apply to all PHI we maintain — past, present, and future. We will post the current Notice in our offices and on our website. A paper copy is available at the front desk at no charge. Material changes will be communicated to patients as required by law.
How We May Use and Disclose Your Information
The following describes how we may use and disclose your PHI. Not every possible use is listed; all uses will fall within these categories or will otherwise be permitted or required by law.
1. Treatment
We may use and disclose your PHI to provide, coordinate, or manage your medical and dental care. This includes sharing information with other providers involved in your care, including the affiliated practices within Imagine Medical & Dental Group, planning and performing treatment, and obtaining referrals when needed.
2. Payment
We may use and disclose your PHI to obtain payment for services — such as verifying your insurance coverage, submitting claims, and working with third parties who assist with billing.
3. Health Care Operations
We may use and disclose your PHI for activities that keep our practices running well — including quality improvement, staff training, credentialing, audits, and legal or compliance services.
4. Appointment Reminders and Health-Related Communications
We may contact you with appointment reminders (by phone, text, email, postcard, or letter) and to inform you about treatment options or related services. If you prefer a specific method of contact, please let us know in writing, and we will honor all reasonable requests.
OTHER USES AND DISCLOSURES PERMITTED OR REQUIRED BY LAW
We may also use or disclose your PHI as allowed or required by applicable federal and state law, including:
- Required by Law: When a specific law requires us to report or disclose PHI.
- Public Health Activities: Reporting diseases, injuries, adverse events, or product defects.
- Abuse, Neglect, or Domestic Violence: To an authorized government authority when required by law.
- Health Oversight Activities: To agencies conducting legally authorized audits, inspections, or investigations.
- Legal Proceedings and Law Enforcement: In response to a court order, subpoena, warrant, or other lawful process.
- Coroners, Medical Examiners, and Funeral Directors: To assist in identifying a deceased person or determining cause of death.
- Organ and Tissue Donation: To facilitate organ or tissue procurement, banking, or transplantation.
- Research: Under certain conditions, with required approvals and privacy safeguards in place.
- To Avert a Serious Threat: To prevent or lessen a serious, imminent threat to health or safety.
- Specialized Government Functions: For certain military, national security, or protective services activities.
- Workers' Compensation: As authorized or required by workers' compensation laws.
SPECIAL PROTECTIONS FOR CERTAIN TYPES OF INFORMATION
Some information is subject to additional federal or state protections. Where required, we will obtain your written permission before using or disclosing this type of information, or we will follow any additional limitations that apply. Specially protected categories include:
- HIV/AIDS-related information
- Genetic information
- Mental health and psychotherapy records
- Reproductive health information, where additional protections apply
- Substance use disorder (SUD) treatment information (see section below)
Substance Use Disorder Records — 42 CFR Part 2
While Imagine Medical & Dental Group is not a federally assisted SUD treatment program, we may receive SUD-related records from other providers as part of coordinating your care. When we receive or maintain such records, these additional protections apply:
If we receive or maintain any information about you from a substance use disorder treatment program that is covered by 42 CFR Part 2 (a "Part 2 Program") 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 operations, we may use and 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 to us.
- General Consent: If you give a general consent to a Part 2 Program for treatment, payment, and health care operations, we may use and disclose those records for those same purposes, consistent with both HIPAA and Part 2.
- Specific Consent: If you provide us a specific, direct consent regarding Part 2 records, we will only use or disclose those records as expressly authorized, unless otherwise required by law.
- Legal Proceedings: We will not use or disclose your Part 2 Program record, or testimony that describes the information contained in your Part 2 Program record, in any civil, criminal, administrative, or legislative 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.
- Redisclosure: Any redisclosure of Part 2 records by our practices will be limited as required by Part 2 regulations and will include required notices of the continued confidentiality protections that apply.
Important: Part 2 imposes stricter confidentiality rules than standard HIPAA in certain circumstances. We will always follow the more protective standard when handling these records.
USES AND DISCLOSURES REQUIRING YOUR WRITTEN AUTHORIZATION
For uses and disclosures not described in this Notice, we will obtain your written authorization before proceeding. You may revoke any authorization in writing at any time. Examples include:
- Most uses and disclosures of psychotherapy notes (if applicable).
- Uses or disclosures for most marketing purposes.
- The sale of your PHI.
- Any other use or disclosure not otherwise permitted or required by law.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
To exercise any of the rights below, please submit a written request to our Privacy Officer (contact information at the end of this Notice).
1. Right to Access Your Records
You may inspect and obtain a copy of the PHI we maintain about you, with limited exceptions. We will provide electronic copies when readily available. A reasonable, cost-based fee may apply for copies or mailing.
2. Right to Request an Amendment
If you believe your PHI is incomplete or inaccurate, you may request in writing that we amend it. We may deny your request in certain circumstances but will provide a written explanation and inform you of your options.
3. Right to an Accounting of Disclosures
You may request a list of certain disclosures of your PHI made in the past six years, excluding disclosures for treatment, payment, and health care operations. The first request in any 12-month period is free; a reasonable fee may apply for additional requests.
4. Right to Request Restrictions
You may request that we limit how we use or disclose your PHI. We are not required to agree to most requests; however, we must honor a request if all of the following are true:
- The disclosure is to a health plan for payment or health care operations;
- The PHI relates solely to a health care item or service for which you (or someone on your behalf) paid us in full; and
- The disclosure is not otherwise required by law.
5. Right to Request Confidential Communications
You may ask us to contact you using a specific method or at a specific address or phone number. We will accommodate all reasonable requests.
6. Right to a Paper Copy of This Notice
You may request a paper copy at any time, even if you previously agreed to receive it electronically. The current Notice is also available on our website and at our front desk.
7. Right to Be Notified of a Breach
If there is a breach of your unsecured PHI as defined by federal law, you have the right to receive written notification without unreasonable delay and no later than 60 days after discovery of the breach.
8. Right to File a Complaint Without Retaliation
You will never be penalized, denied care, or otherwise retaliated against for exercising any of your rights under this Notice or HIPAA.
QUESTIONS AND COMPLAINTS
If you have questions about your privacy rights or believe your rights have been violated, please contact us or file a complaint with HHS:
Privacy Officer
Imagine Medical & Dental Group
1075 Zonolite Rd NE, Atlanta, GA 30306
U.S. Dept. of Health & Human Services
Office for Civil Rights
1-800-368-1019 (TTY: 1-800-537-7697)
You will not be retaliated against for filing a complaint.
ACKNOWLEDGMENT OF RECEIPT
A copy of this Notice will be provided to each patient at or before the first date of service. You may be asked to sign a separate acknowledgment form confirming receipt. Prepared in accordance with 45 C.F.R. §164.520 and 42 C.F.R. Part 2 as amended. This document does not constitute legal advice.