Notice of Privacy Practices

Skilled. Attentive. Compassionate.

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

Mequon Dental Arts (“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. Example: sharing information with specialists, laboratories, or pharmacies involved in your treatment.
  2. Payment
    We may use and share PHI to obtain payment for services rendered. Example: submitting claims to your insurance company or verifying coverage.
  3. Health Care Operations
    We may use and share PHI for administrative, quality assurance, training, auditing, or accreditation purposes. Example: reviewing treatment outcomes or evaluating staff performance.
  4. Appointment Reminders and Communications
    We may contact you via phone, voicemail, text, mail, or email regarding appointments, billing, or follow-up care.
  5. Individuals Involved in Your Care
    We may disclose information to family members or others involved in your care when appropriate, unless you object.
  6. Public Health and Safety
    We may disclose PHI to public health authorities, the FDA, or other agencies for reporting disease, injury, vital events, or adverse events.
  7. Health Oversight Activities
    We may disclose PHI to government agencies for audits, inspections, or investigations as required by law.
  8. Law Enforcement and Legal Requirements
    We may disclose PHI when required by law, court order, subpoena, or administrative request, or to identify or locate a suspect or missing person.
  9. Coroners, Medical Examiners, and Funeral Directors
    We may disclose PHI as needed for them to fulfill their duties.
  10. Research
    We may use or disclose limited PHI for approved research projects, subject to privacy protections and institutional review.
  11. Workers’ Compensation
    We may disclose PHI as authorized to comply with workers’ compensation or similar programs.
  12. Required by Law
    We will disclose PHI when required by federal, state, or local law.
  13. Other Uses and Disclosures with Your Authorization
    Any other use or disclosure of your PHI not described above will be made only with your written authorization. You may revoke an authorization in writing at any time, except to the extent that we have already relied on it.

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 health and billing records, with limited exceptions. We may charge a reasonable fee for copying, mailing, or supplies.
  2. Right to Request Amendment
    If you believe your record is incorrect or incomplete, you may request an amendment. We may deny the request if the record was not created by us or if it is already accurate.
  3. Right to an Accounting of Disclosures
    You may request a list of certain disclosures of your PHI made in the past six years, except those made for treatment, payment, or health care operations.
  4. Right to Request Restrictions
    You may request limits on how your PHI is used or disclosed. We are not required to agree to all requests, but if we do, we will comply unless required by law or in emergencies.
  5. Right to Request Confidential Communications
    You may request that we contact you at a specific phone number, address, or method. We will accommodate reasonable requests.
  6. Right to a Paper Copy of This Notice
    You may request a paper copy of this Notice at any time, even if you agreed to receive it electronically.
  7. Right to Notification of a Breach
    You have the right to be notified if your unsecured PHI is accessed, acquired, or disclosed in a manner not permitted by law.

Our Responsibilities

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

  • We will notify you promptly if a breach occurs that may have compromised your PHI.
  • We will follow the duties and privacy practices described in this Notice.
  • We will not use or share PHI other than as described here unless you authorize us 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. The updated version 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
Mequon Dental Arts
10033 N Port Washington Road, Suite 150
Mequon, WI 53092
Phone: (262) 241-5558
Email: frontdesk@mequondentalarts.com
Website: drrichardrosen.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. Your signature does not indicate agreement with its terms—only that you received it.