HIPPA Privacy-Policy

Greater Brevard Oral and Maxillofacial Surgery & Dental Implants

940 S. Harbor City Blvd

Melbourne, FL 32901

321-332-6000

Notice of Privacy Practices

Effective Date: 09/01/2025

1. Our Pledge Regarding Your Health Information

We understand that your health information is personal. We are committed to protecting your Protected Health Information (PHI). This Notice describes how we may use and disclose your PHI to carry out treatment, payment, healthcare operations, and for other purposes that are permitted or required by law. It also describes your rights regarding your PHI and how you may exercise those rights.

We are required by the Health Insurance Portability and Accountability Act (HIPAA), its implementing regulations, the HITECH Act, and Florida state laws (including statutes regarding confidentiality of medical records) to maintain the privacy of PHI and to provide you with this Notice of our legal duties and privacy practices.

2. Uses and Disclosures of Protected Health Information

Below are the ways we may use and disclose PHI. Not every use or disclosure will be listed. All uses and disclosures will fall under one of the categories described.

Category

How We May Use or Disclose PHI

For Treatment

We may use and disclose PHI to provide, coordinate, or manage your oral surgery, dental implant, and related care. This includes sharing information with other healthcare providers, laboratories, dentists, specialists, or hospitals involved in your care.

For Payment

We may use and disclose PHI so that we can bill and receive payment for the care and services you receive. This includes with your health insurer, Medicare/Medicaid, or third‐party payers.

For

HealthCare Operations

We may use and disclose PHI as necessary for internal operations, quality assessment, training, credentialing, auditing, case management, and legal services.

Appointment Reminders / Treatment Alternatives

We may contact you to remind you of appointments, to inform you of treatment alternatives, or other health‐related benefits or services that may be of interest to you.

As Required By Law

We will disclose PHI when required to do so by federal, state, or local law. This includes reporting abuse, neglect, or domestic violence; responding to subpoenas, law enforcement, or court orders; and complying with public health reporting.

Public Health & Safety

  To prevent or control disease, injury or disability; report adverse       events; for FDA oversight; to notify people of recalls; to reduce a   serious threat to health or safety.

Research

Under certain limited circumstances, with appropriate safeguards, we may disclose PHI for research, subject to your authorization or waiver by an Institutional Review Board (IRB) or similar process.

Health

Oversight Activities

 For audits, investigations, inspections, licensure, or other activities necessary for oversight of the health care system, public benefit programs, or government regulatory compliance.

Legal Proceedings

 In response to a court or administrative order, subpoena, discovery request, or other lawful process, where applicable protections are in place.

Coroners,Funeral Directors,Organ  Donation

 PHI may be disclosed to coroners or medical examiners in certain  cases; to funeral directors as needed; or to organ procurement organizations for donation purposes.

Workers’ Compensation

 When authorized or required, to comply with workers’ compensation laws related to PHI.

3. Uses and Disclosures Requiring Authorization

In any other situation not described above, we will ask for your written authorization before using or disclosing your PHI. For example:

  • Marketing purposes (unless allowed by law and under limited exceptions)

  • Selling PHI

  • Use or disclosure of psychotherapy notes (if applicable)

  • Any other uses not specifically permitted by HIPAA or Florida law

You have the right to revoke any authorization you provide at any time, in writing, except to the extent we have already taken action in reliance on the authorization.

4. Your Rights Regarding Protected Health Information

You have certain rights regarding your PHI. To exercise these rights, submit your request in writing to our Privacy Officer. We may require you to complete specific forms.

Right

What You Can Do

Right to

Inspect &

Copy

You may inspect and obtain a copy of your PHI in a designated record set. If information is maintained in an electronic health record (EHR), and you request it in electronic form, we must provide it in that form, if readily producible. We may charge a reasonable, cost‐based fee for copies.

Right to Amend

If you believe that the PHI we have is incorrect or incomplete, you may request us to amend it. We may deny the request under certain circumstances (e.g. if the information: was not created by us; is not part of our records; would not be permitted to be disclosed; etc.).

Right to an

Accounting

of Disclosures

You have the right to receive a list of certain disclosures we have made of your PHI for purposes other than treatment, payment, and healthcare operations, during the preceding six years (or less, if shorter period allowed by law). We will provide one such accounting free every 12 months; for additional requests, we may impose a reasonable, cost‐based fee.

Right to Request Restrictions

You may request restrictions on certain uses and disclosures of your PHI. We are required to comply only in certain cases (e.g., when you request restriction of disclosure to health plan when you paid out‐of‐pocket in full for the related services).

Right to Request Confidential Communications

 You may ask us to communicate with you in a certain way or at a certain location (e.g. home vs. office vs. alternative address). We will accommodate reasonable requests.

Right to

Receive Notice of a Breach

  If there is a breach of unsecured PHI, we will notify you as required by HIPAA and applicable Florida law.

Right to a

Copyof this Notice

  You may request a paper copy of this Notice at any time, even if you agreed to receive it electronically.

5. Our Responsibilities

  • We are required by law to maintain the privacy and security of PHI.

  • We must notify you in writing if there is a breach of your unsecured PHI.

  • We must follow the terms of this Notice currently in effect.

  • If we change our privacy practices, we will revise this Notice and make the new Notice effective for all PHI we maintain. We will post the updated Notice in our office and on our website, and make copies available upon request.

6. Complaints

If you believe your privacy rights have been violated, you may file a complaint:

  • With our Privacy Officer:

      Name: [Insert Privacy Officer’s Name]

      Address: Greater Brevard Oral and Maxillofacial Surgery & Dental Implants, [Insert Address]

      Phone: [Insert Phone Number]

      Email: [Insert Email]

  • With the Secretary of the U.S. Department of Health & Human Services, Office for Civil Rights at:

      200 Independence Avenue, SW, Washington, DC 20201

      Phone: 1-877-696-6775

  • If applicable under Florida law, with the Florida Department of Health or other relevant state agency.

You will not be retaliated against for filing a complaint.

7. Other Disclosures & State Law Requirements

Florida law may impose additional privacy obligations, including:

  • Reporting requirements (e.g., communicable diseases, abuse, neglect)

  • Medical record confidentiality statutes

  • Duty to disclose certain injuries (e.g. gunshot wounds, abuse) to law enforcement or state authorities.

  • State law may impose different time frames, fees or conditions for your rights (inspection, copying, amendments, etc.). When state law is more protective of your privacy than federal law, we follow state law.

8. Contact Information

If you have any questions or would like to exercise any of your rights, you may contact:

Privacy Officer: Dr. E. Y. Sharaf-Eldeen

Address: Greater Brevard Oral and Maxillofacial Surgery & Dental Implants

940 S. Harbor City Blvd 

Melbourne, FL 32901

Phone: 321-332-6000

Email: [email protected]

9. Acknowledgment of Receipt

You may be asked to sign an acknowledgement that you received this Notice. Signing the acknowledgment does not mean you agree to anything beyond this Notice, only that you received it.

Please keep this Notice for your records.