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COULTER FAMILY DENTISTRY 
NOTICE OF PRIVACY PRACTICES 
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND 
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. 
Please review it carefully.

 
CLIENT RIGHTS AND HIPAA AUTHORIZATIONS

 
The following specifies your rights about this authorization under the Health Insurance Portability 
and Accountability Act of 1996, as amended from time to time (“HIPAA”). 
 

1. Tell your provider if you do not understand this authorization, and the provider will explain it to you. 
 

2. You have the right to revoke or cancel this authorization at any time, except: (a) to the extent 
information has already been shared based on this authorization; or (b) this authorization was 
obtained as a condition of obtaining insurance coverage. To revoke or cancel this authorization, you 
must submit your request in writing to the provider at the following address: 325 Park Place, 
Mishawaka, IN 46545: 
 

3. You may refuse to sign this authorization. Your refusal to sign will not affect your ability to obtain 
treatment, payment, enrollment or your eligibility for benefits. However, you may be required to 
complete this authorization form before receiving treatment if you have authorized your provider to 
disclose information about you to a third party. If you refuse to sign this authorization, and you have 
authorized your provider to disclose information about you to a third party, your provider has the right 
to decide not to treat you or accept you as a patient in their practice. 
 

4. Once the information about you leaves this office according to the terms of this authorization, this 
office has no control over how it will be used by the recipient. You need to be aware that at that point 
your information may no longer be protected by HIPAA. If the person or entity receiving this 
information is not a health care provider or health plan covered by federal privacy regulations, the 
information described above may be disclosed to other individuals or institutions and no longer 
protected by these regulations. 
 

5. You may inspect or copy the protected dental information to be used or disclosed under this 
authorization. You do not have the right of access to the following protected dental information: 
psychotherapy notes, information compiled for legal proceedings, laboratory results to which the 
Clinical Laboratory Improvement Act (“CLIA”) prohibits access or information held by certain 
research laboratories. In addition, our provider may deny access if the provider reasonably believes 
access could cause harm to you or another individual. If access is denied, you may request to have 
a licensed health care professional for a second opinion at your expense. 
 

6. If this office initiated this authorization, you must receive a copy of the signed authorization. 
 

7. Special Instructions for completing this authorization for the use and disclosure of Psychotherapy 
Notes. HIPAA provides special protections to certain medical records known as “Psychotherapy 
Notes.” All Psychotherapy Notes recorded on any medium by a mental health professional (such as 
a psychologist or psychiatrist) must be kept by the author and filed separately from the rest of the 
client’s medical records to maintain a higher standard of protection. “Psychotherapy Notes” are 
defined under HIPAA as notes recorded by a health care provider who is a mental health 
professional documenting or analyzing the contents of conversation during a private counseling 
session or a group, joint or family counseling session and that are separate from the rest of the 
individual’s medical records. Excluded from the “Psychotherapy Notes” definition are the following: 
(a) medication prescription and monitoring, (b) counseling session start and stop times, (c) the 
modalities and frequencies of treatment furnished, (d) the results of clinical tests, and (e) any 
summary of diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to 
date. Except for limited circumstances set forth in HIPAA, in order for a medical provider to release 
“Psychotherapy Notes” to a third party, the client who is the subject of the Psychotherapy Notes must 
sign this authorization to specifically allow for the release of Psychotherapy Notes. Such 
authorization must be separate from an authorization to release other dental records. 
 

8.  You  have  a  right  to  an  accounting  of  the  disclosures  of  your  protected  dental  information  by  the provider  or  its  business  associates.  The  maximum  disclosure  accounting  period  is  the  six  years immediately  preceding  the  accounting  request.  The  provider  is  not  required  to  provide  an  accounting for  disclosures:  (a)  for  treatment,  payment,  or  dental  care  operations;  (b)  to  you  or  your  personal representative;  (c)  for  notification  of  or  to  persons  involved  in  an  individual’s  dental  care  or  payment for  dental  care,  for  disaster  relief,  or  for  facility  directories;  (d)  pursuant  to  an  authorization;  (e)  of  a limited  data  set;  (f)  for  national  security  or  intelligence  purposes;  (g)  to  correctional  institutions  or  law enforcement  officials  for  certain  purposes  regarding  inmates  or  individuals  in  lawful  custody;  or  (h) incident  to  otherwise  permitted  or  required  uses  or  disclosures.  Accounting  for  disclosures  to  dental oversight  agencies  and  law  enforcement  officials  must  be  temporarily  suspended  on  their  written representation that an accounting would likely impede their activities.