Notice of Privacy Practices

Your Information. Your Rights. Our Responsibilities.

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 is issued by Innova Smiles (I-Smile Dental Arts Studio, P.C.), 340 Maple St, Suite 100, Marlborough, MA 01752. Our Privacy Officer is Dr. Ambereen Fatima, DDS. You can reach her by phone at (508) 481-0110, by email at info@innovasmilesdental.com, or in writing at the address above. A paper copy of this notice is available at our front desk at any time. Information collected through this website and its forms is covered separately by our website privacy policy.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your record

• You can ask to see or get an electronic or paper copy of your dental record and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we will tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home, office or cell phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment or our operations. We are not required to agree to your request, and we may say “no” if it could affect your care. If we agree, we may still share this information if you need emergency treatment.
• If you pay for a service or health care item out of pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we have shared information

• You can ask for a list (accounting) of the times we have shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment and health care operations, and certain other disclosures (such as any you asked us to make). We will provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If someone has authority to act as your personal representative, such as a medical power of attorney or a legal guardian, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting our Privacy Officer, Dr. Ambereen Fatima, at (508) 481-0110, info@innovasmilesdental.com or 340 Maple St, Suite 100, Marlborough, MA 01752.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting hhs.gov/hipaa/filing-a-complaint.
• We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and the choice to tell us to:

• Share information with your family, close friends or others involved in your care or in paying for your care
• Share information in a disaster relief situation

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes
• Sale of your information

We do not sell your health information, and we do not use it for fundraising. We are a dental practice, not a hospital, so we keep no patient directory.

Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

• Treat you. We can use your health information and share it with other professionals who are treating you. Example: we send your X-rays and treatment notes to an oral surgeon or other specialist we refer you to.
• Run our organization. We can use and share your health information to run our practice, improve your care and contact you when necessary. Example: we use health information about you to manage your treatment and services, including appointment reminders.
• Bill for your services. We can use and share your health information to bill and get payment from health plans or other entities. Example: we give information about you to your dental insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways, usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see hhs.gov/hipaa/for-individuals.

• Help with public health and safety issues. We can share health information about you for certain situations such as preventing disease, helping with product recalls, reporting adverse reactions to medications, reporting suspected abuse, neglect or domestic violence, and preventing or reducing a serious threat to anyone’s health or safety.
• Do research. We can use or share your information for health research, subject to the conditions the law sets.
• Comply with the law. We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.
• Respond to organ and tissue donation requests. We can share health information about you with organ procurement organizations.
• Work with a medical examiner or funeral director. We can share health information with a coroner, medical examiner or funeral director when an individual dies.
• Address workers’ compensation, law enforcement and other government requests. We can use or share health information about you for workers’ compensation claims; for law enforcement purposes or with a law enforcement official; with health oversight agencies for activities authorized by law; and for special government functions such as military, national security and presidential protective services.
• Respond to lawsuits and legal actions. We can share health information about you in response to a court or administrative order, or in response to a subpoena.

To the extent that we have your substance use disorder patient records, subject to 42 CFR Part 2, we will not share that information for investigations or legal proceedings against you without (1) your written consent or (2) a court order and a subpoena. If we have such records, we will also give you clear notice in advance and a choice about whether to receive any fundraising communications that use them (we do not fundraise).

Massachusetts Law

Massachusetts law gives extra protection to some kinds of health information, for example HIV test results and genetic information, which generally cannot be shared without your written consent. Where state law is stricter than the federal rules described here, we follow the stricter rule.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• 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. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

Changes to the Terms of This Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on this website. This notice is effective October 24, 2026.

Questions

Contact our Privacy Officer, Dr. Ambereen Fatima, DDS, at (508) 481-0110 or info@innovasmilesdental.com. This notice follows the model notice published by the U.S. Department of Health and Human Services Office for Civil Rights.