Communications. You can
request that our practice
communicate with you about your
health and related issues in a
particular manner or at a certain
location. For instance, you
may ask that we contact you at home,
rather than work. We will
accommodate reasonable requests.
You can request a restriction in our
use or disclosure of your health
information for treatment, payment,
or health care operations.
Additionally, you have the right to
request that we restrict our
disclosure of your health
information to only certain
individuals involved in your care or
the payment of your care, such as
family members and friends. We
are not required to agree to you
request; however, if we do agree, we
are bound by our agreement except
when otherwise required by law, in
emergencies, or when the information
is necessary to treat you.
You have the right to inspect and
obtain a copy of the health
information that may be used to make
decisions about you, including
patient medical records and billing
records, but not including
psychotherapy notes. You must
submit your request in writing to
TMJ Disorders Orofacial Pain Center.
You may ask us to amend your health
information if you believe it is
incorrect or incomplete, and as long
as the information is kept by or for
our practice. To request an
amendment, your request must be made
in writing and submitted to TMJ
Disorders Orofacial Pain Center.
You must provide us with a reason
that supports your request for
Right to a copy of this notice.
You are entitled to receive a copy
of this Notice of Privacy Practices.
You may ask us to give you a copy of
this notice at any time. To
obtain a copy of this notice,
contact our front office.
Right to file a complaint. If
you believe your privacy rights have
been violated, you may file a
complaint with our practice or with
the Secretary of the Department of
Health and Human Services. To
file a complaint with our practice,
contact Robyn Palaniuk in the front
office. All complaints must be
submitted in writing. You will
not be penalized for filing a
Right to provide an authorization
for other uses and disclosures.
Our practice will obtain your
written authorization for uses and
dislosures that are not identified
by this notice or permitted by