Notice of Privacy Practices

Effective Date: November 1, 2025

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.

Our Legal Duty

Port Road Dental (“we,” “our,” or “us”) is required by law to maintain the privacy of your protected health information (“PHI”), provide you with this Notice describing our legal duties and privacy practices, and notify you following a breach of unsecured PHI. We must follow the terms of this Notice currently in effect.

How We May Use and Disclose Health Information

We may use and disclose your PHI for the following purposes without your written authorization:

  1. Treatment: We may use and share your information to provide, coordinate, or manage your dental and medical care.
  2. Payment: We may use and share PHI to obtain payment for services rendered.
  3. Health Care Operations: We may use and share PHI for administrative, quality assurance, and related purposes.
  4. Appointment Reminders and Communications: We may contact you regarding visits, billing, or follow-up care.
  5. Individuals Involved in Your Care: We may disclose information to family members or others involved in your care unless you object.
  6. Public Health and Safety: We may disclose PHI to public health authorities or government agencies when required.
  7. Health Oversight Activities: We may disclose PHI to oversight agencies for audits, inspections, or investigations.
  8. Law Enforcement and Legal Requirements: We may disclose PHI when required by law, court order, or subpoena.
  9. Coroners, Medical Examiners, and Funeral Directors: We may share PHI to assist them in performing their duties.
  10. Research: We may disclose PHI for approved research projects under applicable protections.
  11. Workers’ Compensation: We may disclose PHI to comply with workers’ compensation laws.
  12. Required by Law: We will disclose PHI when mandated by federal, state, or local law.
  13. Other Uses with Authorization: Any additional uses require your written authorization, which may be revoked at any time.

Your Rights Regarding Your Health Information

You have the following rights concerning your PHI:

  1. Right to Access: You may request to inspect or obtain a copy of your records. Reasonable fees may apply.
  2. Right to Request Amendment: You may request corrections to your record if you believe it is incomplete or incorrect.
  3. Right to an Accounting of Disclosures: You may request a list of certain PHI disclosures made in the past six years.
  4. Right to Request Restrictions: You may request limitations on how your PHI is used or shared. We may not be able to agree to all requests.
  5. Right to Confidential Communications: You may request to be contacted at a specific phone number or address.
  6. Right to a Paper Copy of This Notice: You may request a paper copy at any time.
  7. Right to Notification of a Breach: You have the right to be notified if your unsecured PHI is compromised.

Our Responsibilities

We are required by law to protect the privacy and security of your PHI. We will notify you if a breach occurs, follow the practices described in this Notice, and will not use or share PHI except as described or authorized by you in writing. We will never sell your information or use it for marketing without your written permission.

Changes to This Notice

We may revise this Notice at any time. Updated versions will apply to all PHI we maintain and will be available in our office and on our website.

Complaints

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

With Us:
Privacy Officer
Port Road Dental
7725 N Port Washington Rd
Fox Point, WI 53217
Phone: (414) 351-6300
Email: portroaddental@gmail.com
Website: portroaddental.com

With the U.S. Department of Health and Human Services:
Office for Civil Rights (OCR)
200 Independence Avenue SW
Washington, DC 20201
Phone: 1-877-696-6775
Website: https://www.hhs.gov/ocr/privacy/hipaa/complaints/

You will not be penalized or retaliated against for filing a complaint.

Acknowledgment of Receipt

You may be asked to sign a form acknowledging receipt of this Notice. This signature confirms only that you received it—not that you agree with its terms.