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Notice of Privacy Practices

Granite City Family Dental (Granite City Family Dental, P.A.)412 2nd Street South, St. Cloud, MN 56301 · 320-555-0142 · https://www.granitecityfamilydental.example Effective date: November 1, 2026. Policy set version 1.0.

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.

Your rights

You have the right to:

  • Get a copy of your paper or electronic medical record. Ask us how. We will provide a copy or a summary, usually within 30 days of your request, in the form and format you ask for if we can readily produce it. We may charge a reasonable, cost-based fee.
  • Ask us to correct your medical record. You can ask us to correct health information about you that you think is incorrect or incomplete. We may say no, but we will tell you why in writing within 60 days.
  • Request confidential communications. You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will say yes to all reasonable requests.
  • 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 our operations. We are not required to agree, and we may say no if it would affect your care. If you pay for a service or item out of pocket in full, you can ask us not to share that information with your health insurer for the purpose of payment or our operations, and we will say yes unless a law requires us to share it.
  • Get a list of those with whom we have shared information. You can ask for an accounting of the times we have shared your health information for six years prior to the date you ask, who we shared it with and why. We include all disclosures except those about treatment, payment and health care operations, and certain other disclosures such as any you asked us to make. We provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another within 12 months.
  • Get a copy of this privacy notice. You can ask for a paper copy at any time, even if you have agreed to receive it electronically.
  • Choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority before we take any action.
  • File a complaint if you feel your rights are violated. You can complain to us using the contact information at the end of this notice, or to the U.S. Department of Health and Human Services Office for Civil Rights. We will not retaliate against you for filing a complaint.

Your choices

For certain health information you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations below, talk to us.

In these cases you have both the right and the choice to tell us to:

  • Share information with your family, close friends or others involved in your care.
  • Share information in a disaster relief situation.

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

  • Marketing purposes.
  • Sale of your information.

We do not use your information for fundraising.

Our uses and disclosures

We typically use or share your health information in the following ways.

  • Treat you. We can use your health information and share it with other professionals who are treating you. Example: a provider treating you for an injury asks another provider about your overall health condition.
  • Run our organization. We can use and share your health information to run our practice, improve your care and contact you when necessary. Example: we use health information about you to manage your treatment and services.
  • Bill for your services. We can use and share your health information to bill and get payment from health plans or other entities. Example: we give information about you to your health insurance plan so it will pay for your services.
  • Remind you of appointments. We may contact you by phone, text message (sms), email and mail to remind you of a scheduled appointment.
  • Tell you about treatment alternatives and health-related services. We may contact you about treatment options or services we offer that may be of interest to you.

How else can we 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 many conditions in the law before we can share your information for these purposes.

  • Help with public health and safety issues. We can share health information about you for certain situations such as preventing disease, helping with product recalls, reporting adverse reactions to medications, reporting suspected abuse, neglect or domestic violence, and preventing or reducing a serious threat to anyone's health or safety.
  • Do research. We can use or share your information for health research under conditions the law sets.
  • Comply with the law. We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.
  • Respond to organ and tissue donation requests. We can share health information about you with organ procurement organizations.
  • Work with a medical examiner or funeral director. We can share health information with a coroner, medical examiner or funeral director when an individual dies.
  • Address workers' compensation, law enforcement and other government requests. We can use or share health information about you for workers' compensation claims; for law enforcement purposes or with a law enforcement official; with health oversight agencies for activities authorized by law; and for special government functions such as military, national security and presidential protective services.
  • Respond to lawsuits and legal actions. We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Minnesota law

Minnesota law gives you additional protection. Under Minnesota Statutes section 144.293, we generally need your signed and dated consent before we release your health records to anyone outside our practice, including other health care providers, unless an exception in Minnesota law applies (for example, a medical emergency, or a release to a related health care entity for your current treatment). Your consent is valid for one year unless you specify a shorter period or revoke it earlier. Where Minnesota law is stricter than federal law, we follow Minnesota law.

Our responsibilities

  • We are required by law to maintain the privacy and security of your protected health information.
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it.
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time by letting us know in writing.

For more information see www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the terms of this notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office and on our website at https://www.granitecityfamilydental.example.

Questions and complaints

Our Privacy Officer is Janelle Okafor, Office Manager. Complaints may be made to Janelle Okafor at 320-555-0142 or [email protected], in person or in writing at the address above.

You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.

This notice is offered in English.

Acknowledgment of Receipt of Notice of Privacy Practices

I acknowledge that I have received, or been offered, a copy of the Notice of Privacy Practices of Granite City Family Dental, effective November 1, 2026.

Patient name: ______________________________________ Date of birth: ______________

Signature: ______________________________________ Date: ______________

If signed by a personal representative, name and relationship to the patient: ______________________________________

For office use. If the acknowledgment could not be obtained, document the good-faith effort:

☐ Patient declined to sign

☐ Patient unable to sign (emergency or capacity)

☐ Notice mailed or delivered electronically on ______________

Documented by: ______________________ Date: ______________