NOTICE OF PRIVACY
PRACTICES

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OMNIBUS Rule — HIPAA NOTICE OF PRIVACY PRACTICES

Legal Entity Practice Name: Twelve Corners Orthodontics & Pediatric Dentistry

Mailing Address: 4 Chelmsford Rd Rochester NY 14618

Effective date: February 16, 2026

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.

For purposes of this Notice, “we,” “our,” and “us” refer to the health care facility named above. “You” and “your” refer to our patients or their authorized legal representatives.

We are committed to protecting the privacy of your Protected Health Information (PHI). We follow the Health Insurance Portability and Accountability Act (HIPAA), its implementing regulations, and all amendments, including the 2024 revisions concerning Substance Use Disorder (SUD) treatment information governed by 42 CFR Part 2.

Our Responsibilities

  • Maintain the privacy of your PHI, including SUD information that may carry extra confidentiality protections under 42 CFR Part 2
  • Provide you with this Notice of our legal duties and privacy practices
  • Notify you following a breach of unsecured PHI
  • Follow the terms of this Notice

How We May Use and Disclose Your PHI Without Your Written Authorization

  • Treatment: We may use and share your PHI with other dentists, physicians, or health care professionals who are treating you.
  • Payment: We may use and share your PHI to bill and get payment from health plans or other entities.
  • Health care operations: We may use and share your PHI to run our practice, improve your care, and contact you when necessary.
  • Public health and safety: We may share PHI for public health reporting, to report abuse or neglect, to avert a serious threat to health or safety, or for product recalls, as permitted by law.
  • Health oversight and law enforcement: We may share PHI with health oversight agencies, for law enforcement purposes, or as required by a court or administrative order, subpoena, or similar process, as permitted by law.
  • Research: We may use or share PHI for research under specific conditions approved by an Institutional Review Board or privacy board, or with your authorization.
  • Workers’ compensation: We may share PHI for workers’ compensation claims and for specialized government functions as permitted by law.
  • Business associates: We may share PHI with third parties who provide services for us under contracts requiring them to protect your information.

Uses and Disclosures That Require Your Authorization

  • Most uses and disclosures of psychotherapy notes (if any)
  • Marketing communications, sales of PHI, and other uses not described in this Notice
  • Sharing your PHI for purposes not permitted by law without your written permission

Your Rights Regarding Your PHI

  • Right to access: You can ask to get an electronic or paper copy of your dental record and other PHI we have about you.
  • Right to request amendment: You can ask us to correct information you think is incorrect or incomplete.
  • Right to request restrictions: You can ask us not to use or share certain PHI for treatment, payment, or health care operations.
  • Right to request confidential communications: You can ask us to contact you in a specific way or to send mail to a different address.
  • Right to an accounting of disclosures: You can ask for a list of certain disclosures we have made of your PHI for the six years prior to your request.
  • Right to a paper copy of this Notice: You can ask for a paper copy of this Notice at any time.
  • Right to choose a personal representative: 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.

Our Duties

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

Questions and Complaints

If you have questions or want to exercise your rights, contact our Privacy Officer:

Name: Michelle Toombs
Address: 4 Chelmsford Rd, Rochester NY 14618
Phone: 585-244-1177
Email: frontdesk@twelvecornersdentistry.com

You may also file a complaint with the U.S. Department of Health & Human Services — Office for Civil Rights, 200 Independence Ave., SW, Washington, DC 20201. Phone: 877-696-6775. We will not retaliate against you for filing a complaint.

NOTE: This NPP is written in plain language. We will post the current Notice in our office and on our website and provide it upon request. We will update this Notice when our privacy practices materially change.