Notice of Privacy Practices

The Grove Family Dental

Effective date: September 1, 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.

This notice applies to the dental care and related services provided by the clinic identified above. “We,” “us,” and “our” refer to that clinic and its workforce. Your health information includes your dental and medical history, treatment records, images, and billing information that identifies you.

Our responsibilities

We are required by law to protect the privacy of your protected health information, give you this notice of our legal duties and privacy practices, and follow the notice currently in effect. We will notify you as required by law if a breach compromises the privacy or security of your information. You may request a paper copy of this notice at any time.

We follow HIPAA and applicable Wisconsin law. When Wisconsin law gives your information greater protection, we follow those stricter requirements. We use safeguards and limit access to information based on job responsibilities. Except where the law allows otherwise, we limit uses and disclosures to the information reasonably necessary for their purpose.

How we use and share your information

We may use or disclose your health information for the purposes below only as permitted or required by applicable law. Some records require additional consent or protections, as explained on page 2.

Treatment. We use information to provide and coordinate your dental care. For example, we may share relevant history or images with a specialist, dental laboratory, pharmacy, or another provider treating you.

Payment. We use information to bill and obtain payment. For example, we may send treatment information to your dental insurer to verify coverage, obtain benefit estimates, or process a claim, subject to your right to restrict certain disclosures when you pay in full yourself.

Health care operations. We use information to manage the practice, improve quality, train staff, review care, conduct audits, and manage business functions. Service providers assisting us must protect information under applicable law and required business associate agreements.

Communications about care. We may contact you about appointments, follow-up care, treatment options, and health-related services. Tell us if you need confidential communications through a particular method or at a different location.

Family and others involved in your care. When permitted by law, we may share information relevant to a person’s involvement in your care or payment if you agree, have an opportunity to object and do not, or we reasonably infer your agreement. If you cannot express a preference, we may use professional judgment to share relevant information in your best interest. We may also assist with notifications or disaster relief as legally permitted.

Other legally permitted disclosures

Subject to applicable legal conditions and any stricter Wisconsin requirements, we may use or share information for the following purposes:

Public health and safety. To report disease, adverse reactions, product problems, suspected abuse or neglect, or other legally reportable conditions; or to prevent or reduce a serious and imminent threat to health or safety.

Oversight and legal requirements. For authorized health oversight, licensing, audits, or investigations; when disclosure is required by law; and to the U.S. Department of Health and Human Services to review our compliance.

Legal proceedings and law enforcement. In response to legally valid court or administrative orders, subpoenas, or other lawful requests, only when applicable privacy-law conditions are met. A request alone does not automatically authorize disclosure.

Other purposes. For legally authorized research; workers’ compensation; organ or tissue donation; coroners, medical examiners, or funeral directors; and authorized military, national security, protective services, or correctional purposes.

Information with additional protections

Wisconsin protections. Wisconsin law restricts disclosure of patient health care records and gives additional protection to certain mental health treatment records, HIV test information, and other specially protected records. We obtain informed consent or written authorization when required and disclose without it only when an applicable legal exception permits or requires disclosure.

Substance use disorder records. If we receive or maintain substance use disorder patient records protected by 42 CFR Part 2, we follow the additional federal protections for those records. Such information may not be used or disclosed in civil, criminal, administrative, or legislative investigations or proceedings against you without your written consent or a qualifying court order and subpoena. Consent for these proceedings must be separate from consent for other purposes. Other uses and disclosures must satisfy Part 2 and applicable state law.

Written authorization. Most uses or disclosures of psychotherapy notes, marketing that requires authorization, and sales of protected health information require your written authorization. Other uses or disclosures not described in this notice also require authorization unless otherwise permitted or required by law. You may revoke an authorization in writing, except to the extent we have already relied on it.

Fundraising. If we contact you for fundraising, you may opt out of future communications. Your choice will not affect treatment or payment. Before using Part 2 records for fundraising, we will give you a clear opportunity to choose not to receive those communications.

Redisclosure. Information disclosed to a recipient may be redisclosed by that recipient and may no longer be protected by HIPAA. Additional federal or Wisconsin protections may still apply, including restrictions on using Part 2 records in proceedings against you.

Your rights

Inspect or obtain copies. You may ask in writing to inspect or receive electronic or paper copies of your dental, medical, and billing records, with limited legal exceptions. We will provide the requested format if readily producible, or agree on an alternative. We generally respond within 30 days, or sooner when required by law. If a legally permitted extension is needed, we will explain it in writing. Any fees will comply with applicable federal and Wisconsin law. If we deny access, we will explain the reason and any available review rights.

Your rights continued

Request corrections. You may ask in writing to amend information you believe is incorrect or incomplete and explain why. We generally respond within 60 days; if a permitted extension is needed, we will notify you in writing. If we deny the request, we will explain why and how you may submit a statement of disagreement.

Request restrictions. You may ask us to limit uses or disclosures for treatment, payment, or operations, or sharing with people involved in your care. We generally do not have to agree. However, if you or someone other than your health plan pays for an item or service in full, we must honor your request not to disclose information about that item or service to your health plan for payment or operations, unless disclosure is required by law.

Request confidential communications. You may ask us to contact you in a particular way or at a different location, such as a specific telephone number or mailing address. We will accommodate reasonable requests. Tell us the method or location you prefer.

Receive an accounting of disclosures. You may request a list of certain disclosures made during the six years before your request. The list generally excludes disclosures for treatment, payment, operations, disclosures to you, and other legally excluded disclosures. The first accounting in a 12-month period is free. We will tell you about any permitted fee for additional requests before proceeding.

Receive a copy and use a representative. You may obtain a paper copy of this notice even if you received it electronically. A person legally authorized to act for you may exercise your rights within the scope of that authority. We verify that authority and follow applicable rules for minors and other represented patients.

Questions and complaints

To ask about this notice, exercise a privacy right, or file a complaint with the clinic, contact our privacy officer using the information below. You may submit a written complaint describing your concern. We will not retaliate against you for filing a complaint.

You may also complain to the U.S. Department of Health and Human Services Office for Civil Rights at www.hhs.gov/hipaa/filing-a-complaint/index.html, by calling 1-877-696-6775, or by writing to 200 Independence Avenue SW, Washington, DC 20201.

Privacy officer or office: Sam Rutter

Clinic: The Grove Family Dental

Address: 109 S. Madison St. Evansville, WI 53536

Telephone: 608-882-4441

Email: info@thegrovefamilysmiles.com

Records and changes to this notice

We retain dental patient records for at least 10 years after the last entry, and longer when required by law. Any transfer or destruction of records will follow applicable Wisconsin requirements and protect confidentiality.

We may revise this notice and make the revised terms apply to information we already maintain and to future information, as allowed by law. The revised notice will show its effective date and will be available in our office, on our website, and upon request.

We may ask you to acknowledge receiving this notice. An acknowledgment confirms receipt; it does not authorize special uses or disclosures of your information. If an acknowledgment is not obtained, we document our efforts as required by law.