Effective Date: May 15, 2026
OUR PLEDGE REGARDING YOUR HEALTH INFORMATION
Elevate Dental Studio understands that your health information is personal. We are committed to protecting it. This Notice describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, and health care operations and for other purposes that are permitted or required by law. It 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 with respect to your PHI
- Follow the terms of the Notice currently in effect
- Notify you in the event of a breach of your unsecured PHI
HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
For Treatment.
We use your PHI to provide dental care, including sharing it with other dentists, physicians, specialists, or staff involved in your care.
For Payment.
We use your PHI to bill for the services we provide, including verifying coverage with your dental insurance plan.
For Health Care Operations.
We use your PHI to evaluate the quality of care we provide, train staff, conduct business management, and other operational activities.
Appointment Reminders and Treatment Information.
We may contact you by phone, text, email, or postal mail to remind you of upcoming appointments, recall you for routine care, or share information about treatment alternatives.
Other Permitted Disclosures.
We may use or disclose your PHI without your written authorization for: public health activities; reporting victims of abuse or neglect; health oversight activities; judicial and administrative proceedings; law enforcement; coroners, medical examiners, and funeral directors; organ donation; research under strict conditions; to avert a serious threat to health or safety; specialized government functions; workers' compensation; and as otherwise required by law.
Disclosures That Require Your Written Authorization.
Most uses and disclosures of psychotherapy notes, uses and disclosures for marketing purposes, and disclosures that constitute a sale of PHI require your written authorization. You may revoke an authorization at any time in writing.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
Right to Inspect and Copy.
You may inspect and obtain a copy of your PHI in our designated record set. Under the Texas Medical Records Privacy Act, we will provide an electronic copy within 15 business days of receiving your written request.
Right to Amend.
If you believe your PHI is incorrect or incomplete, you may request an amendment.
Right to an Accounting of Disclosures.
You may request a list of certain disclosures of your PHI we have made.
Right to Request Restrictions.
You may request a restriction on certain uses and disclosures. We are not required to agree to your request except in limited circumstances — for example, if the disclosure is to a health plan for payment or operations and the service was paid in full out-of-pocket.
Right to Request Confidential Communications.
You may request that we communicate with you in a specific way — for example, only at home, or by mail rather than by phone.
Right to a Paper Copy of This Notice.
You may request a paper copy of this Notice at any time, even if you have agreed to receive it electronically.
Right to Be Notified of a Breach.
You will be notified if your unsecured PHI is breached.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with:
Mackenzie
Compliance OfficerElevate Dental Studio13004 Park Vista Blvd,
Fort Worth, TX 76244
Email: elevatedentalstudio@gmail.com
Phone: (682) 233-0337
U.S. Department of Health and Human Services, Office for Civil Rights — hhs.gov/ocr/complaints · 1-800-368-1019
Texas Attorney General.
Under the Texas Medical Records Privacy Act, you may also file a complaint with the Office of the Attorney General of Texas — texasattorneygeneral.gov/cpd/file-a-consumer-complaint/
You will not be penalized or retaliated against for filing a complaint.
CHANGES TO THIS NOTICE
We reserve the right to change this Notice and to make the new Notice apply to PHI we already have, as well as any information we receive in the future. The most current Notice will be posted on our website and available at our practice. The effective date of the current Notice is noted at the top of this page.