Notice of Privacy Practices

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.

Effective October 13, 2026. This notice applies to Polished Family Dental, its dentists and its team.

Your rights

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

• Get a copy of your dental and health records. You can ask to see or get an electronic or paper copy of your records and other health information we have about you. We will provide a copy or a summary, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
• Ask us to correct your records. 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, a 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 if it would affect your care. If you pay for a service or health care item out of pocket in full, you can ask us not to share that information with your health insurer for 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 your information. You can ask for a list (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 will 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 will provide one list a year for free but may charge a reasonable, cost-based fee if you ask for another one within 12 months.
• Get a copy of this privacy notice. You can ask for a paper copy of this notice at any time, even if you have agreed to receive it electronically. We will give it to you promptly.
• 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.

U.S. Department of Health and Human Services, Office for Civil Rights, 200 Independence Avenue SW, Washington, D.C. 20201, 1-877-696-6775

https://www.hhs.gov/ocr/complaints/index.html

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. Tell us what you want us to do, and we will follow your instructions.

• 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, and to 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 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.
• We never share your information for marketing purposes or sell your information unless you give us written permission.

Our uses and disclosures

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

• To treat you. We can use your health information and share it with other professionals who are treating you. Example: a specialist we refer you to, or a dental lab that makes your crown.
• To run our office. We can use and share your health information to run our practice, improve your care and contact you when necessary. Example: appointment reminders by phone, text or email.
• To 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 dental insurance plan so it will pay for your services.

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, 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.
• 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, and work with a medical examiner or funeral director.
• Address workers' compensation, law enforcement and other government requests: 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.

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. Let us know in writing if you change your mind.

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.

Questions or complaints

Contact our Privacy Officer:

Privacy Officer
Polished Family Dental
7540 S Hulen St
Fort Worth, TX 76133
(817) 294-1090