Your Privacy

 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.


Pine Lake Family Dentistry respects your privacy. We understand that your personal health information is very sensitive. We will not disclose your information to others unless you tell us to do so, or unless the law authorizes or requires us to do so.

The law protects the privacy of the health information we create and obtain in providing our care and services to you. Federal and state law allows us to use and disclose your protected health information for purposes of treatment and health care operations. State law requires us to get your authorization to disclose this information for payment purposes.

For Treatment

  • Information obtained by a dental assistant, hygienist, doctor or our member of our health care team will be recorded in your clinical record and used to help decide what care may be right for you.
  • We may also provide information to others, such as specialists, who will be providing care to you.

For Payment

We request payment on your behalf from your dental insurance plan. Dental insurance companies need information from us in order to process your claims, such as your name, DOB, social security number, employer’s name. Clinical information provided to your dental insurance will include your diagnosis, procedures performed, or recommended treatment, x-rays and photographs, and in some cases a narrative.

For Administrative

  • We may contact you to remind you about your appointments.
  • We may contact you to collect balances owed.


Your Health Information Rights

The health and billing records we create are the property of Pine Lake Family Dentistry. The protected health information in it, generally belongs to you. You have the right to:

  • Receive, read, and ask questions about this Notice.
  • Request in writing a restriction on your record.
  • Request in writing to see and obtain a copy of your protected health information.
  • Request in writing to have us change your health information.
  • When you request, you will be given a disclosure


Our Responsibility

We are required to keep your protected health information private, and only disclose this information to those individuals with whom you’ve given us permission to do so.

We have the right to change our practices regarding the protected health information we maintain. If we make changes, we will update this Notice. You may receive the most current copy of this Notice by requesting it.

We may use and disclose your protected health information without your authorization as follows:

  • To funeral directors/coroners consistent with applicable law to allow them to carry out their duties.
  • To comply with Workers’ Compensation Laws.
  • For public health and safety purposes, as allowed or required by law.
  • To report suspected abuse or neglect to public authorities. 
  • To correctional institutions if you are in jail/prison, as necessary for your health.
  • With the Department of Health, as required by law.