Notice of Privacy Practices

Effective Date: July 29, 2026

Your Information. Your Rights. Our Responsibilities.

THIS NOTICE DESCRIBES HOW MEDICAL AND DENTAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices applies to Lakebrink-Mitts Dental and the dentists, employees, staff members, contractors, and other members of our workforce who provide or support treatment through the practice.

Your Rights

You have the right to:

  • Obtain an electronic or paper copy of your dental and medical records
  • Ask us to correct information in your records
  • Request confidential communications
  • Ask us to limit certain uses or disclosures of your information
  • Obtain a list of certain disclosures we have made
  • Obtain a paper copy of this notice
  • Choose someone to act on your behalf
  • File a complaint if you believe your privacy rights have been violated

Your Choices

In certain situations, you may tell us how you want your health information to be used or shared, including when we:

  • Communicate with family members, friends, or others involved in your care
  • Assist with disaster-relief efforts
  • Send certain marketing or fundraising communications

Our Uses and Disclosures

We may use and disclose your health information to:

  • Treat you and coordinate your care
  • Operate and manage our dental practice
  • Bill for services and obtain payment
  • Communicate with you about appointments and treatment
  • Comply with federal, state, and local law
  • Assist with public-health and safety activities
  • Respond to workers’ compensation, law-enforcement, government, and legal requests
  • Perform other activities permitted or required by law

Your Rights in Detail

When it comes to your health information, you have certain rights. This section explains those rights and some of our responsibilities.

Obtain an Electronic or Paper Copy of Your Records

You may ask to see or receive an electronic or paper copy of your dental record and other health information we maintain about you.

We will generally provide a copy or a summary of your health information within 30 days after receiving your request. We may charge a reasonable, cost-based fee as permitted by law.

In limited circumstances, we may deny access to certain information. When required, we will explain the denial in writing and tell you whether you may request a review of that decision.

Ask Us to Correct Your Records

You may ask us to correct health information about you that you believe is incorrect or incomplete.

We may deny your request, but we will generally explain the reason in writing within 60 days. Even when a correction is denied, you may have the right to submit a written statement of disagreement that will be included with your records.

Request Confidential Communications

You may ask us to contact you in a particular way or at a particular location. For example, you may ask us to call only a certain telephone number, use email, or send mail to a different address.

We will accommodate reasonable requests. You are not required to explain why you are making the request.

Ask Us to Limit What We Use or Share

You may ask us not to use or disclose certain health information for treatment, payment, or healthcare operations.

We are generally not required to agree to your request. We may decline a restriction if, for example, the information is necessary to provide appropriate care. If we agree to a restriction, we will follow it except when the information is needed to provide emergency treatment or when disclosure is otherwise required by law.

If you pay for a healthcare service or item entirely out of pocket, you may ask us not to disclose information about that service or item to your health plan for payment or healthcare-operation purposes. We will agree to that request unless the law requires us to disclose the information.

Obtain a List of Certain Disclosures

You may request an accounting of certain disclosures of your health information made during the six years before the date of your request.

The accounting will not include all disclosures. For example, it generally will not include disclosures made for treatment, payment, or healthcare operations, disclosures made directly to you, disclosures you authorized, or certain other disclosures excluded by law.

We will provide one accounting during any 12-month period at no charge. We may charge a reasonable, cost-based fee for additional requests made within the same 12-month period. We will notify you of the cost before completing the additional request.

Obtain a Copy of This Notice

You may request a paper copy of this notice at any time, even if you previously agreed to receive it electronically. We will provide a paper copy promptly.

Choose Someone to Act for You

If you have given another person medical power of attorney or if someone is your legal guardian or authorized personal representative, that person may exercise your rights and make choices regarding your health information.

Before taking action, we may ask for documentation confirming that the person has legal authority to act on your behalf.

File a Complaint

You may file a complaint with us if you believe your privacy rights have been violated.

To submit a complaint to Lakebrink-Mitts Dental, contact our Privacy Officer using the contact information at the end of this notice. We may ask you to submit the complaint in writing and provide information that will help us investigate it.

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 SW, Washington, DC 20201
  • Calling 1-877-696-6775
  • Visiting the Office for Civil Rights complaint website

We will not retaliate against you for filing a complaint.

Your Choices Regarding Certain Disclosures

For certain health information, you may tell us your preferences about what we disclose.

People Involved in Your Care

You may tell us whether we may disclose relevant health information to:

  • A family member
  • A close friend
  • A caregiver
  • Another person involved in your care
  • A person assisting with payment for your care

If you are unable to communicate your preference, such as during an emergency or because you are unconscious, we may disclose information when we believe the disclosure is in your best interest.

We may also disclose information when necessary to prevent or reduce a serious and imminent threat to the health or safety of you or another person.

Disaster-Relief Activities

We may disclose limited health information to an organization assisting with disaster-relief efforts so that your family or others responsible for your care can be notified about your condition, location, or general status.

You may tell us not to make this disclosure when it is practical for us to ask for your preference.

Marketing and Sale of Information

We will not use or disclose your health information for most marketing purposes without your written authorization.

We will not sell your health information without your written authorization, except where a disclosure is permitted by law without being considered a sale.

Face-to-face communications about treatment and certain communications involving health-related products, services, treatment alternatives, or care coordination may be permitted without a written marketing authorization.

Psychotherapy Notes

Most uses and disclosures of separately maintained psychotherapy notes require written authorization. Lakebrink-Mitts Dental does not ordinarily create or maintain psychotherapy notes as part of dental treatment.

Fundraising

Lakebrink-Mitts Dental does not currently use patient health information for fundraising communications.

If we conduct fundraising in the future as permitted by law, you will have the right to opt out of receiving future fundraising communications.

How We Typically Use or Disclose Your Information

Treatment

We may use your health information and disclose it to dentists, physicians, specialists, dental laboratories, pharmacies, imaging providers, and other healthcare professionals involved in your treatment.

Example: We may send dental images and information about a proposed restoration to a dental laboratory that is making a crown, bridge, denture, aligner, appliance, or other dental product for you.

We may also disclose information to another dentist or healthcare provider to coordinate treatment, obtain a consultation, refer you for specialty care, or respond to a medical concern that may affect your dental treatment.

Healthcare Operations

We may use and disclose your health information to operate our practice, improve the quality of care, train staff, evaluate performance, conduct compliance activities, manage our business, and contact you when necessary.

Example: We may review patient records to evaluate the quality and effectiveness of the dental services we provide.

Healthcare operations may also include:

  • Staff training
  • Quality assessment and improvement
  • Credentialing and professional review
  • Auditing and compliance
  • Business planning
  • Customer service
  • Legal and accounting services
  • Information-technology and cybersecurity support

Payment

We may use and disclose your health information to bill and obtain payment from you, a health plan, an insurance company, or another person responsible for payment.

Example: We may provide information about your diagnosis and treatment to your dental-insurance carrier so it can determine eligibility, coverage, benefits, medical necessity, or payment.

Payment activities may include:

  • Verifying insurance eligibility and benefits
  • Obtaining prior authorization
  • Submitting claims
  • Coordinating benefits
  • Collecting amounts owed
  • Responding to claim reviews or appeals

Appointment Reminders and Communications

We may use your contact information to:

  • Confirm or remind you about appointments
  • Notify you about scheduling changes
  • Follow up after treatment
  • Discuss billing, insurance, forms, or records
  • Provide information about treatment alternatives
  • Tell you about health-related services that may be relevant to your care

These communications may be made by telephone, voicemail, email, text message, mail, or another communication method you have provided or authorized.

Because ordinary email and text messaging may carry privacy risks, you may ask us to communicate with you using a different reasonable method.

Business Associates

We may disclose health information to outside individuals or organizations that perform services for our practice and need access to health information to perform those services.

Examples may include:

  • Billing companies
  • Information-technology providers
  • Cloud-storage or software vendors
  • Secure patient-form providers
  • Payment processors
  • Accountants
  • Attorneys
  • Consultants
  • Document-destruction companies

When required by law, these business associates must agree to appropriately protect your health information.

Other Uses and Disclosures Permitted or Required by Law

We are permitted or required to disclose health information in certain other situations. Before making these disclosures, we must meet the conditions imposed by applicable law.

Public Health and Safety

We may disclose health information for public-health and safety activities, including:

  • Preventing or controlling disease, injury, or disability
  • Reporting adverse reactions to medications or medical products
  • Assisting with product recalls
  • Reporting suspected abuse, neglect, or domestic violence
  • Preventing or reducing a serious threat to health or safety
  • Reporting information to public-health authorities as required by law

Health Oversight

We may disclose health information to health-oversight agencies for activities authorized by law, such as audits, inspections, investigations, licensing activities, disciplinary proceedings, and monitoring of the healthcare system.

Research

We may use or disclose health information for research when the research has been properly approved and all applicable legal requirements have been satisfied.

When required, we will obtain your written authorization before using or disclosing identifiable health information for research.

Compliance With the Law

We will disclose information about you when federal, state, or local law requires us to do so.

We may disclose information to the U.S. Department of Health and Human Services if it requests information to determine whether we are complying with federal privacy law.

Abuse, Neglect, or Domestic Violence

We may disclose health information to an appropriate government authority when we reasonably believe a patient may be a victim of abuse, neglect, or domestic violence and the disclosure is authorized or required by law.

Organ and Tissue Donation

We may disclose health information to organ-procurement organizations or similar entities when necessary to facilitate organ, eye, or tissue donation and transplantation.

Coroners, Medical Examiners, and Funeral Directors

We may disclose health information to a coroner, medical examiner, or funeral director when permitted or required by law.

Workers’ Compensation

We may use or disclose health information as authorized or required for workers’ compensation claims or similar programs that provide benefits for work-related injuries or illness.

Law Enforcement

We may disclose health information for certain law-enforcement purposes when the disclosure is permitted or required by law.

Examples may include responding to a court order, warrant, subpoena, summons, administrative request, or a request to identify or locate a suspect, fugitive, missing person, or material witness.

Government Functions

We may disclose health information for certain authorized government functions, including:

  • Military and veterans’ activities
  • National-security and intelligence activities
  • Protective services
  • Correctional-institution or law-enforcement custody activities

Lawsuits and Legal Proceedings

We may disclose health information in response to a court or administrative order.

We may also disclose information in response to a subpoena, discovery request, or other lawful process when the requirements of applicable privacy law have been satisfied.

Substance Use Disorder Patient Records

To the extent that Lakebrink-Mitts Dental receives or maintains substance use disorder patient records protected by 42 CFR Part 2, those records may be subject to additional confidentiality protections.

Part 2 records, or testimony describing the contents of those records, generally may not be used or disclosed in a civil, criminal, administrative, or legislative investigation or proceeding against you unless:

  1. You provide written consent that specifically permits the use or disclosure; or
  2. The use or disclosure is authorized by a qualifying court order and accompanied by a subpoena or other legal requirement compelling the disclosure.

These protections apply only to records that are subject to 42 CFR Part 2. Not every reference to substance use or substance use treatment in a dental record is necessarily a Part 2 record.

Uses and Disclosures Requiring Written Authorization

We will obtain your written authorization before using or disclosing your health information for a purpose not described in this notice, unless the use or disclosure is otherwise permitted or required by law.

An authorization may be required for:

  • Most marketing uses
  • The sale of protected health information
  • Most uses or disclosures of psychotherapy notes
  • Other uses or disclosures not otherwise permitted by law

You may revoke an authorization at any time by notifying us in writing. Revocation will not affect actions we already took in reliance on your authorization.

Our Responsibilities

Lakebrink-Mitts Dental is required by law to:

  • Maintain the privacy and security of your protected health information
  • Provide you with this notice describing our legal duties and privacy practices
  • Follow the terms of the notice currently in effect
  • Notify affected individuals following a breach of unsecured protected health information when notification is required by law

We will not use or disclose your health information except as described in this notice or as otherwise permitted or required by law.

If you give us written authorization to use or disclose information, you may revoke that authorization in writing at any time. Your revocation will not affect uses or disclosures already made in reliance on the authorization.

Changes to This Notice

We reserve the right to change the terms of this notice and our privacy practices.

Any revised notice may apply to all health information we maintain, including information created or received before the revised notice became effective.

When we make a material change, the updated notice will be:

  • Available upon request
  • Available at our dental office
  • Posted in a clear and prominent location at our office
  • Published on our website

The effective date of the current notice will appear at the beginning of the notice.

Questions, Requests, and Complaints

For questions about this notice, to exercise your privacy rights, to request a copy of your records, or to file a privacy complaint, contact:

Privacy Officer
Lakebrink-Mitts Dental
105 Stewart Court, Suite 140
Liberty, Missouri 64068

Phone: (816) 792-4455
Email: [email protected]