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Notice of privacy practices

Effective [date to be set when approved]

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 is from Gentle Endodontics (Nivine El-Refai, D.D.S., M.S.D., Inc.), 3985 Medina Road, Suite 160, Medina, OH 44256. It covers Dr. El-Refai and everyone who works in our office. In this notice, “health information” means information that identifies you and is about your health, your care or payment for your care. Examples are your dental records, x-rays and 3D scans, health history, and billing and insurance details.

If you have questions about this notice, call our Privacy Officer at 330-721-1350, or write to Privacy Officer, Gentle Endodontics, at the address above.

Your rights

You have these rights about your health information. To use any of them, ask at the front desk, call our Privacy Officer at 330-721-1350, or write to us at the address above. We may ask you to make your request in writing and to show ID.

Get a copy of your records

  • You can ask to see or get a copy of your dental and billing records and other health information we have about you, on paper or electronically.
  • We will give you a copy, or a summary if you agree to one, within 30 days of your request. If we need more time, we will tell you why in writing, and we will take no more than 30 more days.
  • If you ask for an electronic copy, we will give it to you in the form and format you ask for, if we can easily produce it that way. If we cannot, we will work with you to agree on another electronic format you can read.
  • You can ask us in writing to send a copy directly to a person you choose.
  • We may charge a reasonable, cost-based fee for copies. We will tell you the fee before we make them.
  • If we say no to any part of your request, we will tell you why in writing. We will also tell you if you can ask to have that decision reviewed.

Ask us to correct your records

  • You can ask us to correct health information about you that you think is incorrect or incomplete. Tell us why you think it should change.
  • We will answer within 60 days. If we need more time, we will tell you why in writing, and we will take no more than 30 more days. We may say no, but if we do, we will tell you why in writing.
  • If we say no, you can give us a written statement of disagreement, and we will keep it with your records.

Ask us to contact you in a certain way

  • You can ask us to contact you in a specific way, for example only at a certain phone number, or by mail to a different address.
  • We will say yes to all reasonable requests, and we will not ask you why.

Ask us to limit what we use or share

  • You can ask us not to use or share certain health information for treatment, payment or running our practice. You can also ask us not to share it with family or friends involved in your care. We do not have to agree, and we may say no if it would affect your care. If we agree, we will follow the limit unless the information is needed to give you emergency treatment.
  • If you pay in full, out of pocket, for a service or health care item, you can ask us not to share information about it with your dental or health plan for payment or for running our practice. We will say yes unless a law requires us to share that information.

Get a list of who we have shared your information with

  • You can ask for a list (an accounting) of the times we shared your health information in the six years before your request. The list shows who we shared it with and why.
  • The list will include every time we shared your information except for treatment, payment and running our practice, and certain other times, such as sharing you asked us to do. We will answer within 60 days, or tell you in writing if we need up to 30 more days.
  • The first list in any 12 months is free. If you ask for another within the same 12 months, we may charge a reasonable, cost-based fee. We will tell you the fee first, so you can change or withdraw your request.

Get a copy of this notice

  • You can ask for a paper copy of this notice at any time, even if you have agreed to receive it electronically. Ask at the front desk, or call us and we will mail you one.
  • This notice is also posted in our office and on our website at www.gentleendo.com/notice-of-privacy-practices.

Choose someone to act for you

  • If you have given someone health care power of attorney, or if someone is your legal guardian, that person can use your rights and make choices about your health information. We will make sure the person has this authority before we act on their request.
  • For a patient under 18, a parent or legal guardian usually acts for the child. Under Ohio law, a parent who is not the child’s residential parent has the same access to the child’s records as the residential parent, unless a court order limits it. Please give us a copy of any court order that affects a parent’s access.

File a complaint if you feel your rights are violated

  • You can complain to us or to the U.S. Department of Health and Human Services. See Contact and complaints below.

Your choices

For some health information, you can tell us your choices about what we share. If you have a clear preference about how we share your information in the situations below, tell us, and we will follow your instructions.

  • Family, friends and others involved in your care. We may share information with a family member, close friend or other person you name who is involved in your care or helps pay for it. For example, this may be someone who comes to your appointment with you or drives you home. We may also let them know where you are and how you are doing. You can tell us not to.
  • If you cannot tell us your choice. If you are not able to tell us your preference, for example in an emergency, we may share information if we believe it is in your best interest. We may also share information when needed to lessen a serious and imminent threat to health or safety.
  • After a patient’s death. We may share relevant information with family members or others who were involved in the patient’s care or helped pay for it, unless the patient told us not to.
  • Disaster relief. We may share information with a disaster relief organization so it can help let your family know where you are and how you are doing. You can tell us not to.

How we use and share your health information

To treat you

We use your health information and share it with other professionals who are treating you. For example, after your visit we send a report of our findings and treatment to the dentist who referred you or to your general dentist, so they can complete your care. The report may include your x-rays and any 3D scan images. We may also share information with a physician, another dental specialist or a pharmacy involved in your care.

To bill for your care

We use and share your health information to bill and get payment from health plans and others. For example, we give your dental plan information about your treatment, and x-rays when it asks for them, so it will pay for your care. If you choose to pay through a patient financing plan, we share the billing details it needs.

To run our practice

We use and share your health information to run our practice, improve your care and contact you when needed. For example, we may use your records to review the quality of our care and to train our team. We may also contact you to remind you of an appointment or to follow up after treatment.

Some companies do work for us that involves your health information, such as the company that provides our practice software and patient portal. They must agree in writing to protect your information and to use it only as our contract with them allows.

How else we can use or share your health information

We are allowed or required to share your information in other ways, usually in ways that contribute to the public good, such as public health and research. We have to meet the conditions in the law before we can share your information for these purposes.

Substance use disorder treatment records

Some records from substance use disorder treatment programs have extra protection under a federal law, 42 CFR Part 2. If we have records like these about you, we will not use or share them, or testimony about what they contain, to investigate you or bring criminal charges against you, or in any civil, criminal, administrative or legislative proceeding against you, unless:

  • you give written consent, or
  • a court orders it after you, or the holder of the records, has had notice and a chance to be heard, as 42 CFR Part 2 provides.

Before the records are used or shared, the court order must also come with a subpoena or other legal requirement that compels us to share them. This limit applies to every use and sharing described in this notice, including for law enforcement and lawsuits.

When the law allows or requires it

  • Public health and safety. We may share information to prevent or control disease, report reactions to medicines or problems with medical products, help with product recalls, and prevent or lessen a serious threat to anyone’s health or safety.
  • Abuse, neglect or domestic violence. Ohio law requires dentists to report suspected abuse or neglect of a child or of a person with a developmental disability, and suspected abuse, neglect or exploitation of certain adults 60 or older. We may also report other suspected abuse, neglect or domestic violence to the agencies that receive these reports, when the law requires or allows it.
  • Research. We may use or share your information for health research only when federal privacy law allows it, for example with the approval of a research review board.
  • Complying with the law. We share information when federal, state or local law requires it, including with the U.S. Department of Health and Human Services if it wants to see that we are complying with federal privacy law.
  • Health oversight. We may share information with agencies that oversee health care, such as the Ohio State Dental Board, for audits, investigations, inspections and licensing.
  • Organ and tissue donation. We may share information with organizations that handle organ, eye or tissue donation.
  • Coroners, medical examiners and funeral directors. We may share information with a coroner or medical examiner, for example to help identify a person from dental records, and with a funeral director as needed.
  • Workers’ compensation. We may share information for workers’ compensation claims and similar programs, as the law allows.
  • Law enforcement. We may share information with law enforcement officials when the law requires or allows it. For example, we may report certain injuries, such as gunshot or stab wounds, respond to a court order or warrant, or report a crime that happens in our office.
  • Special government functions. We may share information for military and veterans activities, national security and intelligence, and protective services for the President and others. If you are an inmate or otherwise in custody, we may share information with the correctional institution or law enforcement official that has custody of you.
  • Lawsuits and legal actions. We may share information in response to a court or administrative order. We may also share it in response to a subpoena or other legal request, but only within the Ohio limits described under “Records in court cases” below.

Uses that need your written permission

We never use or share your information for these purposes unless you give us written permission:

  • Marketing
  • Sale of your health information
  • Most sharing of psychotherapy notes

We also will not use photos, x-rays or other information that identifies you on our website or social media, or in lectures or publications, unless you give us written permission.

Any other use or sharing of your health information that this notice does not describe will happen only with your written permission. You can take back your permission at any time by telling us in writing. Taking it back does not undo anything we already did because of it.

Extra protections under Ohio law

Where Ohio law protects your health information more than federal law does, we follow Ohio law. For example:

  • HIV test results and AIDS diagnoses. Ohio law strictly limits who may learn that you were tested for HIV, your test results, or that you have been diagnosed with AIDS or an AIDS-related condition. We share this information only as Ohio law allows. For example, we may share it if you give us specific written permission that names who may receive it and for how long, or with other health care providers who need it to care for you. A general release of your records is not enough.
  • Records in court cases. Ohio law treats what you tell your dentist, and our records of your care, as privileged, which gives them extra protection in court cases. In a lawsuit or other court case, we will generally release your records in response to a subpoena only if you give written permission, if a court orders it, or if Ohio law says the privilege does not apply. For example, it may not apply when you have filed a claim about your own injury or care.
  • Looking at your records. You can look at your records in our office during regular business hours at no charge.
  • Free copies for Social Security claims. If you need your records to support a claim for Social Security or Supplemental Security Income benefits, we will give you one copy at no charge. To get it, show us that the claim has been filed.

Our responsibilities

  • We are required by law to keep your health information private and secure, to give you this notice of our legal duties and privacy practices, and to notify you if a breach affects your unsecured health information.
  • We must follow the terms of the notice currently in effect and give you a copy of it.

Changes to this notice

We can change the terms of this notice, and the changes will apply to all information we have about you, including information we had before the change. The new notice will be posted in our office and on our website, and we will give you a copy if you ask.

Contact and complaints

Contact our Privacy Officer

Privacy Officer, Gentle Endodontics
3985 Medina Road, Suite 160, Medina, OH 44256
330-721-1350 (ask for the Privacy Officer)

How to file a complaint

  • If you believe we have violated your privacy rights, you can complain to us by calling or writing to our Privacy Officer.
  • You can also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. Complaints to the Office for Civil Rights must be in writing:
  • We will not retaliate against you or treat you differently for filing a complaint.

Effective date

This notice takes effect on [date to be set when approved].

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