NOTICE OF PRIVACY PRACTICES
Muna Strasser D.D.S., P.C.
Phone: 309-277-0220
Fax: 309-277-0219
Effective Date: 02/16/2026
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
OUR LEGAL DUTY
We are required by law to maintain the privacy and security of your protected health information (“PHI”) under the Health Insurance Portability and Accountability Act (HIPAA). We must:
Protect your health information.
Provide you with this Notice of our legal duties and privacy practices.
Follow the terms of this Notice currently in effect.
Notify you promptly if a breach occurs that may have compromised the privacy or security of your information.
We will not sell your protected health information without your explicit written authorization.
HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
1.Treatment
We may use and disclose your health information to provide, coordinate, or manage your dental care. Examples include:
Examining and treating your teeth
Prescribing medications
Referring you to specialists
Sharing information with laboratories
2.Payment
We may use and disclose your information to bill and collect payment from you, your insurance company, or a third party.
Important Right (2026 Clarification):
If you pay in full out-of-pocket for a specific service, you have the right to request that we not disclose that information to your health plan. We must honor that request unless disclosure is required by law.
3. Health Care Operations
We may use your information for office operations such as:
Quality assessment
Staff training
Licensing and accreditation
Business management
Legal compliance activities
USES AND DISCLOSURES WITHOUT YOUR AUTHORIZATION
We may use or disclose your information without your written authorization when permitted or required by law, including:
Public health reporting
Reporting abuse, neglect, or domestic violence
Health oversight audits
Judicial or administrative proceedings
Law enforcement purposes
Workers’ compensation claims
Research (subject to legal requirements)
To prevent serious threats to health or safety
Specialized government functions
As required by federal or state law
BUSINESS ASSOCIATES
We may share your information with third-party service providers (called “Business Associates”) who perform services for us. These parties are legally required to protect your information and comply with HIPAA.
APPOINTMENT REMINDERS & COMMUNICATIONS
We may contact you via phone, voicemail, text message, email, or mail regarding:
Appointment reminders
Treatment follow-ups
Billing matters
You may request confidential communications or alternative contact methods at any time.
Standard messaging and data rates may apply to electronic communications.
USES THAT REQUIRE YOUR WRITTEN AUTHORIZATION
We will obtain your written authorization for:
Marketing communications (where required by law)
Sale of protected health information
Most disclosures of psychotherapy notes (if applicable)
Uses not otherwise described in this Notice
You may revoke your authorization in writing at any time.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
You have the right to:
1.Access Your Records
You may inspect or obtain a copy of your health records in paper or electronic format.
You may also direct us to transmit an electronic copy to a third-party application or person of your choosing.
We will respond within 30 days (with one permitted 30-day extension if necessary).
Reasonable, cost-based fees may apply.
2. Request an Amendment
You may request correction of inaccurate or incomplete information.
3. Request Restrictions
You may request restrictions on certain uses or disclosures.
We are required to agree to restrictions involving disclosures to health plans when you pay in full out-of-pocket.
4. Request Confidential Communications
You may request communications in a specific way (for example, at work instead of home).
5. Receive an Accounting of Disclosures
You may request a list of certain disclosures made within the past six years.
6. Receive a Paper Copy of This Notice
You may request a paper copy at any time.
BREACH NOTIFICATION
If a breach of your unsecured protected health information occurs, we will notify you without unreasonable delay and no later than 60 days after discovery, as required by federal law.
COMPLAINTS
If you believe your privacy rights have been violated, you may file a complaint with:Office for Civil Rights
U.S. Department of Health and Human Services
www.hhs.gov/ocr
We will not retaliate against you for filing a complaint.
CHANGES TO THIS NOTICE
We reserve the right to change this Notice at any time. Updated versions will be posted in our office and on our website.
FINANCIAL POLICY
I understand there is a cancellation policy in this office, and agree to pay any failed appointments or appointments cancelled without 24 hour notice at our hourly rate ($120 per hour). I agree to pay any bills incurred at the time of service or make approved payment arrangements should I be unable to pay a bill in full. Any unpaid balance without a payment arrangement will incur 6% interest billed monthly. In the event of a signed payment arrangement, I agree to make payment by the 22nd of each month. I understand there will be a monthly late charge of $30.00 posted to my account on the 23rd in the event of a missed payment. Should any account be referred outside for collection, I agree to pay all costs including agency fees, court costs and reasonable attorney fees. Should I (insured) have insurance that pays me directly and not the dental office, I (insured) agree to pay for services at the time they are rendered. Insurance claims in these instances will be withheld until the office has received payment in full.
ACKNOWLEDGEMENT OF RECEIPT
I acknowledge that I have received a copy of the Notice of Privacy Practices.
