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American Fork Orthodontics, PC

Alan C Carter DDS, MS and Rodney G Northrup DDS, MS

Notice of Privacy Practices for American Fork Orthodontics PC, 36 South 1100 East American Fork, UT 84003 (801) 756-6246

We are required by law to maintain the privacy of your protected health information (PHI), to provide individuals with notice of our legal duties and privacy practice with respect to protected health information, and to notify affected individuals following a breach of protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 4/1/2016 and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law and to make new Notice provisions effective for all protected health information that we maintain. When we make a significant change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at our practice location, and we will provide copies upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this notice.

Your Authorization: In addition to our use of your health information for the following purposes, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

Uses and Disclosures of Health Information

We may use and disclose your health information for different purposes, including treatment, payment, and health care operations For each of these categories, we have provided a description and an example. Some information, such as HIV related information, genetic information, alcohol and/or substance abuse records and mental health records may be entitled to special confidentiality protections under applicable state or federal law. We will abide by these special protections as they pertain to applicable cases involving these types of records

Treatment: We may use or disclose your health information for your treatment. For example, we may disclose your health information to a dentist, specialist or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain reimbursement for treatment and services you received from us. Payment activities include billing, collecting, claims management, and determination of eligibility and coverage to obtain payment from you, an insurance company, or third party. For example, we may send claims to your dental health plan containing certain health information.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, conducting training programs, and licensing activities.

To You Or Your Personal Representative: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to your personal representative, but only if you agree that we may do so.

Individuals Involved In Your Care or Payment of Your Care: We may disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your absence or incapacity or in emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Disaster Relief: We may use or disclose your health information to assist in disaster relief efforts.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Public Health Activities: We may disclose your health information for public health activities, including disclosures to: Prevent or control disease, injury or disability; Report child abuse or neglect; Report reactions to medications or problems with products or devices; Notify a person of a recall, repair, or replacement products or devices; Notify a person who may have been exposed to a disease or condition, or Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody the protected health information of an inmate or patient under certain circumstances.

Security of HHS: We will disclose your health information to the Secretary of the US Department of Health and Human Services when required to investigate or determine compliance with HIPAA

Worker’s Compensation: We may disclose your PHI for law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order.

Health Oversight Activities: We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and credentialing, as necessary for licensure and for government to monitor the health care system, government programs, and compliance with civil right laws.

Judicial and Administrative Proceedings: 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 health information about you in response to a subpoena, discovery request, or other lawful process instituted by someone else involved in the dispute, but only if efforts have been made, either by the requesting party or us, to tell you about the request or to obtain an order protecting the information request.

Research: We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information.

Coroners, Medical Examiners, and Funeral Directors: We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine cause of death. We may disclose PHI to funeral directors consistent with applicable law to enable them to carry out their duties.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Display of Pictures: We may display pictures with personal information. For example, we may post a newspaper clipping of you or we may post a picture on boards for patients who recently got braces on or off.

Fund raising: We may contact you to provide information about our sponsored activities, including fundraising programs, as permitted by applicable law. If you do not wish to receive such information from us, you may opt out of receiving communications.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, texts, emails, postcards, or letters).

Incidental Disclosure: Other patients and third parties may see or overhear incidental disclosure about your treatment, scheduling, etc.

Other Uses and Disclosures of PHI

Your authorization is required, with a few exceptions, for disclosure of psychotherapy notes, use or disclosure of PHI for marketing, and for the sale of PHI. We will also obtain your written authorization before using or disclosing your PHI for purposes other than those provided for in the Notice (or as otherwise permitted or required by law). You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization.

Your Health Information Rights

Access: You have the right to look at or get copies of your health information, with limited exceptions. You must make a request in writing. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by send us a letter to the address at the end of this Notice. If you request information that we maintain on paper, we may provide photocopies. If you request information that we maintain electronically, you have the right to an electronic copy. We will use the form and format you request if readily producible. We will charge you a reasonable cost-based fee for the cost of supplies and labor of copying, and for postage if you want copies mailed to you. Contact us using the information listed at the end of this Notice for an explanation of our fee structure.

Disclosure Accounting: With the exception of certain disclosures, you have the right to an accounting of disclosures of your health information in accordance with applicable laws and regulations. To request an accounting of disclosures of your health information, you must submit you request in writing to the Privacy Official. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Right to Request a Restriction: You have the right to request additional restrictions on our use or disclosure of your PHI by submitting a written request to the Privacy Official. Your written request must include 1. What information you want to limit, 2. Whether you want to limit our use, disclosure or both, and 3. To whom you want the limits to apply. We are not required to agree to your request except in the case where the disclosure is to a health plan for purposes of carrying out payment or health care operations, and the information pertains solely to a health care item or service for which you, or a person on your behalf (other than the health plan), has paid our practice in full.

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or at alternative locations. You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request. We will accommodate all reasonable requests. However, if we are unable to contact you using the ways or locations you have requested we may contact you using the information we have

Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances. If we agree to your request, we will amend your record(s) and notify you of such. If we deny your request for an amendment, we will provide you with a written explanation of why we denied it and explain your rights.

Right to Notification of a Breach: You will receive notifications of breaches of your unsecured protected health information as required by law.

Electronic Notice: You may receive a paper copy of this notice upon request, even if you have agreed to receive this notice electronically on our website or by email.

Questions and Complaints

If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or if you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact: Privacy Officer and Business Manager, Janet Rose
Telephone: (801) 756-6246

***Please sign and return this form and thank you for placing your trust in us!

Our new “Notice of Privacy Practices” dated 4/1/2016 can be reviewed at our front desk or online at You can also request your own copy by contacting our Privacy Officer and Business Manager: Janet Rose (801) 756-6246.

Our small practice has always verified insurance benefits over the phone and filed claims on paper forms through the mail. However, one insurance company has recently decided they will only accept electronic claim forms. Although this currently involves just one patient in our office, it now requires us to have specific privacy policies for all of our patients. Therefore, we are reviewing our office procedures and training our staff to make sure we keep your Private Health Information (PHI) as safe as possible.

American Fork Orthodontics PC

Acknowledgment of Receipt of

“Notice of Privacy Practices”

I, _______________________________________,

have received/reviewed a copy of this office’s Notice of Privacy Practices.

Print Patient Name____________________________________________________

Relation to patient_____________________________________________________



For Office Use Only


We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices,

but acknowledgment could not be obtained because:

_____ Individual refused to sign

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