Summary Notice of Privacy Practices

(This is a Summary of the Policy Available for Review at Your Request). Our Practice is dedicated to maintaining the privacy of your individually identifiable health information (IIHI) that we have created and accumulated regarding you and the treatment and services we provide to you. By law, we must maintain the confidentiality of your IIHI and provide you with this notice of our legal duties and privacy practices. By federal and state law, we must follow the terms of the Notice of Privacy Practices that is in effect at any time. The terms of this notice apply to all records containing your IIHI that are created or retained by Our Practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that Our Practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our Practice will post a summary of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.


  • Treatment. Our doctors, nurses and staff may use your IIHI to treat you. Payment. Our Practice may use and disclose your IIHI in order to assure coverage and bill and collect payment for services and items you receive from us.
  • Health Care Operations. Our Practice may use and disclose your IIHI to operate our business. Evaluating the quality of your care is an example.
  • Appointment Reminders. Our Practice may use and disclose your IIHI to contact you to remind you of an appointment or notify you of treatment related information. Examples include post cards, e-mail or telephone calls.
  • Treatment Options. Our Practice may use and disclose your IIHI to inform you of potential treatment options or alternatives.
  • Health-Related Benefits and Services. Our Practice may use and disclose your IIHI to inform you of health-related benefits or services that may interest you.

Disclosure Required by Law. Our Practice will use and disclose your IIHI when we are required to do so by federal, state or local law.


  • Public Health Risks. To public health authorities that are authorized by law to collect information for public health activities. Examples include maintaining records of births and deaths, reporting abuse or neglect and preventing/controlling communicable disease.
  • Health Oversight Activities. To a health oversight agency for activities authorized by law. Examples can include inspections, audits, licensure and other activities necessary for the government to monitor the health care system.
  • Lawsuits and Similar Proceedings. In response to a court or administrative order, a discovery request, subpoena, or other lawful process by another party involved in a dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.
  • Lawful Enforcement. If asked to do so by a law enforcement official regarding a crime victim in certain situations: concerning a death we believe has resulted from criminal conduct; because of a warrant, summons, court order, subpoena or similar legal process; to identify/locate a suspect, material witness, fugitive or missing person; to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator); to identify a deceased individual.
  • Organ and Tissue Donation. To organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor.
  • Research. For research purposes in certain limited circumstances. We will obtain your written authorization to use your IIHI for research purposes except when: (a) our use or disclosure was approved by an Institutional Review Board or a Privacy Board; (b) we obtain the oral or written agreement of a researcher that (i) the information being sought is necessary for the research study; (ii) the use or disclosure of your IIHI is being used only for the research and (iii) the researcher will not remove any of your IIHI from our practice; or (c) the IIHI sought by the researcher only relates to decedents and the researcher agrees either orally or in writing that the use or disclosure is necessary for the research and, if we request it, to provide us with proof of death prior to access of the IIHI of the decedents.
  • Serious Threats to Health or Safety. To reduce or prevent a serious threat to the health and safety of you, any other individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.
  • Military. If you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.
  • National Security. To federal officials for intelligence and national security activities authorized by law; also to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.
  • Inmates. To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.
  • Workers’ Compensation. For workers’ compensation and similar programs.


  • Confidential Communications. To request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, at home, rather than work. In order to request confidential communication, you must make a written request.
  • Requesting Restrictions. To request a restriction in our use or disclosure of your IIHI for treatment, payment or health care operations or to request that we restrict our disclosure of your IIHI to only certain individuals involved in your care or the payment of your care. We are not required to agree to your request. If we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. Your request must be in writing and must have a clear and concise description of the following: (a) the information you wish restricted; (b) whether you are requesting to limit our practice’s use, disclosure or both; and (c) to whom you want the limits to apply.
  • Inspection and Copies. To inspect and obtain a copy of the IIHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing in order to inspect and/or obtain a copy of your IIHI. Our Practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our Practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of any denial.
  • Amendment. To request that we amend your health information if you believe it is incorrect or incomplete, and to request an amendment for as long as the information is kept by or for Our Practice. Your request must be made in writing. You must provide us with a reason that supports your request for amendment. Our Practice may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the IIHI kept by or for the practice; (c) not part of the IIHI which you would be permitted to inspect and copy; or (d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.
  • Accounting of Disclosures. To request an “accounting of disclosures.” This is a list of certain non-routine disclosures Our Practice has made of your IIHI for non-treatment or operations purposes. Use of your IIHI as part of the routine patient care in our practice is not required to be documented. You must submit your request in writing. All requests must state a time period, which may not be longer than (6) years from the date of the request and may not include dates before April 14, 2003. The first list you request within a 12 month period is free of charge, but our practice may charge you for additional lists within the same 12 month period. Our practice will notify you of the costs involved with additional requests and you may withdraw your request before you incur any costs.
  • Right to a Paper Copy of This Notice. To receive a paper copy of this Summary or the Complete Notice of Privacy Practices. You may request this notice at any time.
  • Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with Our Practice or with the Department of Health and Human Services. To file a complaint with Our Practice, contact the Privacy Officer in writing. You will not be penalized for filing a complaint.
  • Right to Provide an Authorization for Other Uses and Disclosures. Our Practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your IIHI may be revoked at any time in writing. Please note: we are required to retain records of your care.


Privacy Officer:

Dr. Stephen Mulder DDS
1787 Grand Ridge Court
Suite #203
Grand Rapids, MI 49525
Telephone: 616.447.1700

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