ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

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Sunshine Family Dentistry

Effective Date: February 5, 2026

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THIS NOTICE EXPLAINS HOW WE MAY USE OR SHARE YOUR HEALTH INFORMATION AND HOW YOU CAN SEE OR GET A COPY. PLEASE READ IT CAREFULLY-KEEPING YOUR HEALTH INFORMATION PRIVATE IS VERY IMPORTANT TO US.

CONTACT INFORMATION

If you have questions, concerns, or want another copy of this notice, please contact our Privacy Officer:

Telephone: 701-390-9676, 3001 Yorktown Dr. #4, Bismarck, ND 58503

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The Health Insurance Portability & Accountability Act of 1996 (HIPAA) requires us to protect your health information—whether electronic, paper, or verbal—from loss, damage, or misuse. We may change our privacy practices and this Notice at any time, as allowed by law. Changes will apply to all your health information, including records we received before the change. Any revised Notice will be posted in our office and will be available upon request. This federal law gives you, the patient, significant new rights to understand and control how your health information is used.

USES AND DISCLOSURES OF YOUR PHI

Treatment: We may share your health information with other dentists or healthcare providers who are helping with your care. For example, we might share information with an oral surgeon to decide if you need surgery.

Payment: We may use your health information to bill your insurance or you for dental services. For example, your insurance may need information about the dates you received treatment.

HEALTH CARE OPERATIONS: We may use your information to improve our services, train our staff, do audits, handle legal matters, and manage our business. Health care operations include:

• Quality assessment and improvement: Evaluating and improving the quality of care we provide.
• Provider evaluation: Reviewing the skills and performance of our dental providers, including training and certification.
• Audits and legal services: Handling audits, legal reviews, and preventing fraud.
• Business management: Activities such as planning, billing, customer service, complaint, and resolution.

REMINDERS: We may contact you by phone, text, email, or mail to remind you of appointments or share other information about your dental care. You may request that we not leave voicemail messages or that we contact you only at a certain phone number. We will accommodate reasonable requests.

YOUR AUTHORIZATION: You (or your legal personal representative) may give us written permission to use your health information or share it with anyone for any purpose. When your health information is shared to a recipient pursuant to your authorization or as otherwise permitted by law, the recipient may be permitted to redisclose that information. In some circumstances, the redisclosed information may no longer be protected by HIPAA, depending on the recipient and applicable law. You may take back or “revoke” your written authorization at any time, except if we have already acted based on your authorization. Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect. This includes sharing health information for marketing or fundraising purposes.

FAMILY, FRIENDS AND OTHERS INVOLVED IN YOUR CARE OR PAYMENT FOR CARE: We may share your health information to a family, friends or others involved in your care or payment, limited to relevant information. We may use your name, location and general condition to notify, or to assist an appropriate public or private agency to locate and notify, a person responsible for your care in appropriate situations, such as a medical emergency or during disaster relief efforts. We will provide you with an opportunity to object to these disclosures, unless you are not present or are incapacitated or it is an emergency or disaster relief situation. In those situations, we will use our professional judgment to determine whether sharing your health information is in your best interest under the circumstances.

PLAN SPONSORS: If your dental insurance coverage is through an employer’s sponsored group dental plan, we may share summary information with the plan sponsor.

PUBLIC HEALTH AND BENEFIT ACTIVITIES: We may use and share your PHI, without your permission, when required by law and when authorized by law for the following kinds of public health and benefit activities;

• for public health, including to report disease and vital statistics, child abuse, adult abuse, neglect or domestic violence;
• to avert a serious and imminent threat to health or safety;
• for health care oversight, such as activities of state insurance commissioners, licensing and peer review authorities and fraud prevention agencies;
• for research;
• in response to court and administrative orders and other lawful process;
• to law enforcement officials with regard to crime victims and criminal activities;
• to coroners, medical examiners, funeral directors and organ procurement organizations;
• to the military, to federal officials for lawful intelligence, counterintelligence, and national security activities, and to correctional institutions and law enforcement regarding persons in lawful custody; and
• as authorized by state worker’s compensation laws.

SPECIAL PROTECTIONS FOR SUD RECORDS (IF APPLICABLE): Substance Use Disorder (SUD) records have enhanced protections under federal law governing (SUD) records (42 CFR Part 2). SUD records may not be used or shared without your written consent, except as permitted or required by law. If a use or disclosure of health information described above in this notice is prohibited or materially limited by other laws that apply to us, it is our intent to meet the requirements of the stricter law will apply.

BUSINESS ASSOCIATES: We may share your health information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. Our business associates are required to protect the privacy of your information and are not allowed to use or share any information other than as specified in our contract.

DATA BREACH NOTIFICATION PURPOSES: You have the right to be notified if a breach of your protected health information occurs. We will notify you if a breach occurs that may have compromised the privacy or security of your information following HIPAA breach notification timelines. We may use your contact information to provide legally required notices of unauthorized acquisition, access or disclosure of your health information.

ADDITIONAL RESTRICTIONS ON USE AND DISCLOSURE: Federal law prohibits us from using or disclosing protected health information for the purpose of investigating or imposing liability related to the lawful seeking, obtaining, providing, or facilitating of reproductive health care, or for identifying any person for such purposes. In certain circumstances, we must obtain a written attestation before disclosing protected health information potentially related to reproductive health care. Federal and North Dakota laws may require enhanced protections for certain highly confidential health information.

‘Highly Confidential Information’ may include confidential information under federal laws governing:

1. HIV/AIDS – NDCC § 230717
2. Mental Health records – NDCC § 2503.1
3. Genetic tests – NDCC § 230615.1
4. Alcohol and drug abuse records / SUD – NDCC § 5006.1
5. Sexually transmitted diseases and reproductive PHI – NDCC § 231210
6. Child or adult abuse or neglect, including sexual assault – NDCC § 502501

YOUR RIGHTS

1. You have the right to inspect and receive a copy of your health records, including in electronic or machine-readable form when available. We may charge a reasonable, cost-based fee for copies. You may also request a paper copy of this NPP at any time, even if you have agreed to receive it electronically.
2. You have the right to request confidential communications and restrictions on how we use or share your protected health information. We are not required to agree to most requested restrictions; however, we must agree to a request not to share information to your health plan for services paid in full out-of-pocket, unless disclosure is required by law.
3. Choose someone to act for you (medical power of attorney)
4. You have a right to ask to get an Accounting of Disclosures. This is a list of certain disclosures we have made of your protected health information in the past six (6) years, excluding disclosures made for treatment, payment, health care operations, and certain other disclosures permitted by law.
5. You have a right to amend your health information. You have a right to request amendment to be made to your health records by submitting the request in writing to our privacy officer. Your request does not guarantee the amendment, but does guarantee that it will be reviewed and considered.
6. You may request that we transmit your health information directly to a third-party application or service designated by you. We will comply with such requests in compliance with the patient’s security measures and HIPAA safeguards.
7. You may give written authorization for health information use or disclosure for other purposes, such as marketing. We will not sell your health information unless the law allows it or you give permission and you may opt out of fundraising communications at any time by contacting our Privacy Officer. Opting out will not affect your treatment or payment.
8. If you believe your rights are being denied or your health information is not being protected, you can:
   1. File a complaint with your provider or health insurer
   2. File a complaint with the U.S. Government

COMPLAINTS

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your PHI, about amending your PHI, about restricting our use or disclosure of your PHI, or about how we communicate with you about your PHI (including a breach notice communication), you may contact our Privacy Officer to register either a verbal or written complaint.  You can also file a complaint online or call the Office for Civil Rights at 1-800-368-1019.  We support your right to privacy of your PHI. You will not be retaliated against for filing a complaint with us or with the U.S. Department of Health and Human Services.