Privacy Policy
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.
The office is committed to protecting your privacy, and we have adopted privacy practices to protect the information we gather from you. We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. The Notice of Privacy Practices (“Notice”) describes the privacy practices of the office and will tell you about the ways in which we may use and disclose medical information about you and how you can get access to this information. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information with respect to your “Protected Health Information” (as defined by the Health Insurance Portability and Accountability Act of 1996 and its regulations, as amended from time to time).
**Consumer Information is not shared with third parties for marketing purposes**
We typically use or share your health information in the following ways:
- Treat you. We can use your health information and share it with other professionals who are treating you. An example of this would be a doctor treating you for an injury asks another doctor about your overall health condition.
- Bill for your services. We can use and share your health information to bill and get payment from health plans or other entities. An example of this would be sending a bill for your visit to your insurance company for payment.
- Run our office. We can use and share your health information to run our practice, improve your care, and contact you when necessary. An example would be an internal quality assessment review.
How else can we use or share your health information. We are allowed or required to share your information in other ways – usually to 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. For more information, see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
- Help with public health and safety issues. We can share health information for certain situations, such as: preventing disease, reporting suspected abuse, neglect, or domestic violence, preventing/reducing a serious threat to anyone’s health or safety.
- Comply with law. We can share information about you if state or federal law requires is, including the Department of Health and Human Services.
- Do Research. We can use and share information for health research.
- Family and Friends. We may disclose your health information to a family member or friend who is involved in your medical care or to someone who helps pay for your care. We may also use or disclose your health information to notify (or assist in notifying) a family member, legally authorized representative or other person responsible for your care of your location, general condition or death. If you are a minor, we may release your health information to your parents or legal guardians when we are permitted or required to do so under federal and applicable state law.
- Organ and tissue donation requests. We can share information about you to organ procurement organizations
- Medical examiner or funeral director. We can share information with a coroner, medical examiner, or funeral director when an individual dies.
- Worker compensation, law enforcement requests, and other governmental requests. We can share health information for worker compensation claims, law enforcement purposes, with health oversight agencies for activities allowed by law, and other specialized government functions (e.g., military and national security)
- Lawsuits and legal actions. We can share health information in response to court or administrative order, or in response to a subpoena.
When it comes to your health information, you have certain rights, we typically use or share your health information in the following ways:
- Get an electronic or paper copy of your medical information. You have the right to inspect and/or obtain a copy of your medical information maintained in a designated record set. If we maintain your medical information electronically, you may obtain an electronic copy of the information or ask us to send it to a person or organization that you identify. To request to inspect and/or obtain a copy of your medical information, you must submit a written request to our Privacy Officer. If you request a copy (paper or electronic) of your medical information, we may charge you a reasonable, cost-based fee.
- Ask us to correct your medical record. You can ask us to correct health information about you that you think is incomplete or incorrect. We may say “no” to your request, but we’ll tell you why in writing within 60 days.
- Confidential communications. You can ask us to contact you in a specific way (for instance home or office phone) or to send mail to a different address for items such as appointment reminders. We will say yes to all reasonable requests.
- Limits on what we use and share. You can ask us NOT to share certain health information for treatment, payment, or operations. We are not required to agree to your request, and if it affects your care, we may say no.
- Accounting of disclosures. You can ask for a list (accounting) of the times we have shared your health information for the prior six years. We will include all disclosures, except those about treatment, payment, and operations. We will provide one accounting for free, but may charge a reasonable, cost-based fee if you ask for another within 12 months.
- Privacy Notice. You can ask and receive a paper copy of this notice at any time.
- Complaint. You can file a complaint if you feel we have violated your rights, with the office at the address below, or you with the Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Ave, SW, Room 509F HHH Bldg., Washington, D.C. 20201, calling 1-877-696-6775, or by visiting: www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.
By providing your mobile phone number and opting into our SMS messaging service, you consent to the collection, use, and storage of your information as outlined in this policy. We collect your number when you sign up through our website, app, or directly with our staff through our intake form (s) and use it solely for transactional, informational, and promotional messages related to our services. Your information is protected with industry-standard security measures and is not shared with third parties for marketing purposes, though it may be shared with our SMS service provider strictly for message delivery.
In these cases we will never share your information unless given written permission: Marketing purposes, fundraising, and the sale of information. We may also create and distribute de-identified health information by removing all references to individually identifiable information.
We may, without prior consent, use or disclose protected health information to carry out treatment, payment, or healthcare operations in the following circumstances:
- If we are required by law to treat you, and we attempt to obtain such consent but are unable to contain such consent; or
- If we attempt to obtain your consent but are unable to do so due to substantial barriers to communicating with you, and we determine that, in our professional judgment, your consent to receive treatment is clearly inferred from the circumstances.
State Law
We will not use or share your information if state law prohibits it. Some states have laws that are stricter than the federal privacy regulations, such as laws protecting HIV/AIDS information or mental health information. If a state law applies to us and is stricter or places limits on the ways we can use or share your health information, we will follow the state law. If you would like to know more about any applicable state laws, please ask our Privacy Officer.
We are required by law to maintain the privacy and security of your protected health information. We will promptly let you know if a breach occurs that may have compromised the privacy and security of your information. This notice is effective as of 2003 and we are required to abide by the terms of the Notice of Privacy Practices. We will not share your information other than described in here unless we receive written authorization. We can change the terms of notice, and any new notices will be available upon request, in our office, and on our website.
If you have any questions or want more information about this notice or how to exercise your health information rights, you may contact our Privacy Officer, Thomas Southam by mail at: the office address or telephone. You have the right to exercise any of the actions in the above document, and the Privacy Officer will guide you through the process.
HIPAA NOTICE • REQUIRED FEDERAL DISCLOSURE
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.
- Get a copy of your record
- Correct your record
- Request confidential comms
- Ask us to limit what we share
- List of those we’ve shared with
- Get a copy of this notice
- Choose someone to act for you
- File a complaint
- Share with family/friends
- Share in disaster relief
- Marketing (requires permission)
- Sale of info (requires permission)
- Psychotherapy notes (permission)
- Opt out of fundraising
- Treat and care for you
- Run our practice
- Bill for your services
- Public health & safety
- Research
- Comply with the law
- Legal actions & subpoenas
Section 1 — 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 an electronic or paper copy of your medical record
You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
You can ask us to contact you in a specific way (for example, home, office, or cell 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 to your request, and we may say “no” — for example, if it could affect your care. If we agree, we may still share information in the event that you need emergency treatment.
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will 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 the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
If someone has authority to act as your personal representative, such as if someone has your 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 and can act for you before we take any action.
Note for parents of orthodontic patients: When a parent or legal guardian accompanies a minor patient, we will provide this notice to the parent or guardian and make a good-faith effort to obtain written acknowledgment of receipt, as required by 45 CFR §164.520(c)(2)(ii).
Section 2 — 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 described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
You have both the right and choice to tell us to:
- Share information with your family, close friends, or others involved in your care or payment for your care
- 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 go ahead and 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 unless you give us written permission for:
Marketing purposes • Sale of your information • Most sharing of psychotherapy notes
Fundraising
We may contact you for fundraising efforts, but you can tell us not to contact you again. If we have your substance use disorder patient records (subject to 42 CFR Part 2), we will give you clear and conspicuous notice in advance and a meaningful choice about whether to receive fundraising communications that use your Part 2 information.
Section 3 — Our Uses & Disclosures
How we typically use or share your health information
Treat You
We can use your health information and share it with other professionals who are treating you.
Example: Your orthodontist coordinates with your general dentist or an oral surgeon to plan your treatment.
Run Our Organization
We can use and share your health information to run our practice, improve your care, and contact you when necessary.
Example: We use health information about you to manage your treatment and services, conduct quality reviews, and train our staff.
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 health insurance plan so it will pay for your orthodontic services.
How else we may use or share your health information
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.
Important — Substance Use Disorder Records (42 CFR Part 2): In all cases below, if we have substance use disorder patient records about you subject to 42 CFR Part 2, we cannot use or share information in those records in civil, criminal, administrative, or legislative investigations or proceedings against you without (1) your written consent or (2) a court order and a subpoena.
Help with Public Health and Safety Issues
We can share health information for certain situations 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, subject to applicable legal requirements and protections.
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’re complying with federal privacy law.
Respond to Organ and Tissue Donation Requests
We can share health information about you with organ procurement organizations.
Work with a Medical Examiner or Funeral Director
We can share health information with a coroner, medical examiner, or funeral director when an individual dies.
Address Workers’ Compensation, Law Enforcement & Other Government Requests
We can use or share health information about you for workers’ compensation claims; for law enforcement purposes; with health oversight agencies; 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.
Redisclosure Notice (required under 45 CFR §164.520): Please be aware that PHI disclosed by our practice may be redisclosed by the recipient and may no longer be protected under the HIPAA Privacy Rule, unless stronger federal confidentiality protections (such as 42 CFR Part 2 for SUD records) apply.
Section 4 — 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 in this notice 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.
For more information, visit: www.hhs.gov/hipaa/for-individuals/notice-privacy-practices
Section 5 — 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. Any material changes will be posted with an updated effective date, consistent with 45 CFR §164.520(b)(1)(v)(C).
Section 6 — File a Complaint If You Feel Your Rights Are Violated
You can complain if you feel we have violated your rights by contacting us using the information in the Contact section below.
You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights:
- By mail: 200 Independence Avenue, S.W., Washington, D.C. 20201
- By phone: 1-877-696-6775
- Online: www.hhs.gov/hipaa/filing-a-complaint
Section 7 — Contact & Privacy Officer
Privacy Officer
Dr. Woolaver
Phone
(480) 240-9393
chris@clearsmilesaz.com
Mailing Address
4425 E Agave Rd Ste 126, Phoenix, AZ 85044, US
Office Hours
- Monday: 8:00 AM - 5:00 PM
- Tuesday: 8:00 AM - 5:00 PM
- Wednesday: 8:00 AM - 5:00 PM
- Thursday: 8:00 AM - 5:00 PM
- Friday: 8:00 AM - 12:00 PM
Fax
N/A
U.S. Department of Health & Human Services — Office for Civil Rights:
200 Independence Avenue, S.W., Washington, D.C. 20201 | 1-877-696-6775 | www.hhs.gov/hipaa/filing-a-complaint
If you participate in a patient portal for accessing your records online, you may contact us through the portal’s secure messaging system in addition to the methods listed above.
This notice was prepared in accordance with the HIPAA Privacy Rule (45 CFR §164.520) and 42 CFR Part 2. Content based on the HHS OCR Model Notice for Health Care Providers, last reviewed February 13, 2026.
Effective Date: February 16, 2026