Effective Date: June 2026
Last Reviewed: June 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.
1. Our Commitment to Your Privacy
Midwest Family Dental Care (“Practice,” “we,” “us,” or “our”) is committed to protecting the privacy of your health information. We create a record of the care and services you receive at our practice. We need this record to provide you with quality care and to comply with certain legal requirements.
This Notice of Privacy Practices (“Notice”) describes how we may use and disclose your Protected Health Information (PHI) to carry out treatment, payment, or healthcare operations, and for other purposes permitted or required by law. This Notice also describes your rights to access and control your PHI.
We are required by law to:
Maintain the privacy of your PHI
Provide you with this Notice of our legal duties and privacy practices
Notify you following a breach of your unsecured PHI
Abide by the terms of the Notice currently in effect
2. How We May Use and Disclose Your Health Information
The following categories describe the ways we may use and disclose your PHI. Not every use or disclosure in a category will be listed, but all of the ways we are permitted to use and disclose information will fall within one of the following categories.
A. Treatment
We may use and disclose your PHI to provide, coordinate, or manage your dental care and any related services. For example, we may disclose your PHI to a dental specialist or other healthcare provider to whom we refer you for treatment. We may also share PHI with our clinical staff (dentists, hygienists, dental assistants) at any of our locations to coordinate your care.
B. Payment
We may use and disclose your PHI to obtain payment for services we provide to you. For example, we may submit claims to your dental insurance company and include information about your treatment to obtain reimbursement. We may also contact you regarding payment of your account.
C. Healthcare Operations
We may use and disclose your PHI for our healthcare operations. These activities are necessary to run our practice and make sure that all of our patients receive quality care. For example, we may use PHI to review our treatment and services and to evaluate the performance of our clinical staff.
D. Appointment Reminders
We may use and disclose your PHI to contact you as a reminder that you have an appointment for treatment or medical care at our practice. We may contact you by phone, text message, email, or postcard.
E. Treatment Alternatives
We may use and disclose your PHI to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
F. Health-Related Benefits and Services
We may use and disclose your PHI to tell you about health-related benefits or services that may be of interest to you.
G. Business Associates
We may disclose your PHI to our business associates — companies or individuals that perform certain functions on our behalf or provide us with certain services. We require our business associates to protect the privacy of your health information through a signed Business Associate Agreement (BAA). Examples include billing services, IT vendors, and appointment reminder services.
H. Required by Law
We will disclose your PHI when required to do so by federal, state, or local law. For example, we are required to report certain communicable diseases to public health authorities.
I. Public Health Activities
We may disclose your PHI for public health activities, including to report disease, injury, or disability as required by law; to report reactions to medications or problems with products; and to notify people of product recalls.
J. Health Oversight Activities
We may disclose your PHI to a health oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the healthcare system and government programs.
K. Lawsuits and Disputes
If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose your PHI in response to a subpoena, discovery request, or other lawful process.
L. Law Enforcement
We may release your PHI if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons, or similar process; to identify or locate a suspect, fugitive, material witness, or missing person; about the victim of a crime; about a death we believe may be the result of criminal conduct; or in emergency circumstances to report a crime.
M. Serious Threats to Health or Safety
We may use and disclose your PHI when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
3. Uses and Disclosures That Require Your Authorization
For uses and disclosures beyond those described in Section 2, we will ask for your written authorization. You may revoke your authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your PHI for the reasons covered by your written authorization, except where we have already relied on that authorization.
We must obtain your specific written authorization for:
Most uses and disclosures of psychotherapy notes
Uses and disclosures of PHI for marketing purposes
Disclosures that constitute a sale of PHI
Other uses and disclosures not described in this Notice
4. Your Rights Regarding Your Health Information
You have the following rights regarding the PHI we maintain about you:
A. Right to Inspect and Copy
You have the right to inspect and obtain a copy of PHI that may be used to make decisions about your care, including dental records and billing records. To inspect or copy your PHI, submit your request in writing to our Privacy Officer. We may charge a reasonable fee for copies. We will respond to your request within 30 days.
B. Right to Amend
If you believe that PHI we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment as long as the information is kept by our practice. To request an amendment, submit your request in writing to our Privacy Officer and provide a reason that supports your request.
C. Right to an Accounting of Disclosures
You have the right to request an accounting of disclosures we have made of your PHI for reasons other than treatment, payment, and healthcare operations, and certain other activities. Your request must be submitted in writing to our Privacy Officer and must state a time period, which may not be longer than six years.
D. Right to Request Restrictions
You have the right to request a restriction on the PHI we use or disclose for treatment, payment, or healthcare operations. We are not required to agree to your request. If we agree, we will comply with your request unless the information is needed to provide you emergency treatment. We must agree to your request to restrict disclosure to a health plan if the disclosure is for payment or healthcare operations and you have paid out-of-pocket in full for the services.
E. Right to Request Confidential Communications
You have the right to request that we communicate with you about dental matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. We will accommodate all reasonable requests.
F. Right to a Paper Copy of This Notice
You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time, even if you have agreed to receive this Notice electronically. To obtain a paper copy, contact our Privacy Officer.
G. Right to Be Notified of a Breach
You have the right to be notified in the event that we (or a Business Associate) discover a breach of your unsecured PHI. We will notify you by first-class mail or email (if you have indicated a preference for email) within 60 days of the discovery of the breach.
5. Our Locations
This Notice applies to all Midwest Family Dental Care locations:
Jenison, MI: 2064 Baldwin St, Suite A, Jenison, MI 49428 — (616) 457-2299
Grand Rapids, MI: 2020 Division Ave S, Grand Rapids, MI 49507 — (616) 245-2767
Kalamazoo, MI: 714 N 9th St, Kalamazoo, MI 49009 — (269) 388-5832
Portage, MI: 706 W Centre Ave, Portage, MI 49024 — (269) 323-1536
Kokomo, IN: 2714 Rockford Ln, Kokomo, IN 46902 — (765) 453-9040
6. Changes to This Notice
We reserve the right to change this Notice and to make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice in our offices and on our website. The Notice will contain the effective date on the first page.
7. Complaints
If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact our Privacy Officer in writing. We will not retaliate against you for filing a complaint.
To file a complaint with HHS:
U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
Phone: 1-800-368-1019
Website: hhs.gov/ocr/complaints
8. Contact Our Privacy Officer
For questions about this Notice or to exercise your rights, contact:
Privacy Officer
Midwest Family Dental Care
2064 Baldwin St, Suite A
Jenison, MI 49428
Phone: (765) 233-6826
Email: [email protected]
Website: midwestfamilydentalcare.com