top of page

Patient Privacy

Work Desk

Notice of Privacy Practices (Effective May 18, 2022)

This Notice describes how medical information about you may be used and disclosed and how you can get access to this information.


Please review carefully.

Who Will Follow This Notice

This Notice describes the patient privacy practices of Dr. Leo R. Cullinan and that of:

  • Any health-care professional authorized to enter information into your chart at our facility.

  • All departments and units of the orthodontic practice of Dr. Leo R. Cullinan.

  • Any member of a volunteer group we allow to help you while you are at our facility.

  • All employees and personnel, including contracted.

  • Other independent health-care practitioners who have agreed to follow and abide by the “joint notice of privacy practices” terms described below.

Our Pledge and Responsibilities Regarding Your Protected Health Information

We understand that medical information about you and your health is personal. We are committed to protecting health information about you and are required under federal and state law to take steps to protect this information. Under federal privacy laws, this information is called protected health information. Protected health information includes certain information we have created or received that identifies you, including information regarding your health or payment for your health at our facility, whether by hospital personnel, your personal dentist, or other practitioners involved in your care. It includes your medical records and personal information, such as your name, social security number, address, and phone number.


We are required by law to:

  • Take steps to protect the privacy of the medical information that identifies you;

  • Provide you this Notice of our legal duties and privacy practices with respect to medical information about you; and

  • Follow the terms of the Notice that is currently in effect.

Uses and Disclosures of Your Protected Health Information

We use and disclose your protected health information in many ways related to your treatment, payment for your care, and our health-care operations. Some examples of how we may use or disclose your protected health information are listed below.


We may use or disclose your protected health information to provide you with medical treatment or services:

  • To doctors, nurses, technicians, or other medical personnel who are involved in your care.

  • To different departments to coordinate activities, such as prescriptions, lab work and x-rays.

  • To others outside our practice who may be involved in your dental/medical care after you leave our facility.


Federal and state laws may place additional limitations on the use of your protected health information for drug or alcohol abuse, sexually-transmitted diseases, or mental health treatment.


As permitted by law, we may use or disclose your protected health information in relation to payment.

  • To bill for treatment and services you receive at our facility.

  • To collect payment for treatment and services you receive at our facility.

  • To obtain prior approval for treatment and services from your insurance plan.


We may use or disclose your protected health information in relation to health system operations.

  • To administer or support our business activities or those of other health-care organizations (as allowed by law) including providers and insurance plans.

  • To other individuals (such as consultants and attorneys) and organizations that help us with our business activities. (Note: If we share your protected health information with other organizations for this purpose, they also must agree to protect your privacy.)


These uses and disclosures are necessary to operate the practice and ensure patients receive quality care. Examples could include review of treatment to evaluate staff or identify training needs, to review outcomes of care, or to send you a patient satisfaction survey.


We may also use or disclose your protected health information in the following miscellaneous circumstances:

  • Appointment Reminders – To contact you as a reminder that you have an appointment for treatment at our facility.

  • Treatment Alternatives – To tell you about or recommend possible treatment options or alternatives.

  • Health-Related Benefits and Services – To tell you about health-related benefits, services, or medical education classes.

  • Individuals Involved in Your Care – To a caregiver who may be a friend or family member involved in your care.

  • Research – For research purposes, under certain circumstances. (All research projects, however, are subject to special approval process. We will ask for your specific permission if the researcher will have access to your name, address, or other information that reveals who you are or if the researcher will be involved in your care at our facility.)

  • As Required by Law – When required to do so by federal, state, or local law. We may also use or disclose your protected health information in the following special situations:

    • Military – As required by law, if you are a member of the armed forces.

    • Worker’s Compensation – For worker’s compensation or similar programs, including filing a report of accident with the state Labor & Industries Department or another worker’s compensation program.

    • Disaster Relief – To an organization assisting in a disaster relief effort so that your family and friends can be notified about your general health condition and location.

  • Public Health and Safety – To agencies when necessary to prevent a serious threat to your health and safety or health and safety of the public or another person. These activities generally include the following:

    • To prevent or control disease, injury or disability;

    • To report births and deaths;

    • To report child abuse or neglect;

    • To report reactions to medications or problems with products;

    • To notify people of recalls of products they may be using;

    • To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;

    • To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure when required or authorized by law.

  • Health Oversight Activities – To a health oversight agency for activities authorized by law, such as audits, investigations, inspections, and licensure.

  • Lawsuits and Disputes – In response to a court or administrative order, subpoena, discover request or other lawful process, if you are involved in a lawsuit or a dispute.

  • Law Enforcement – To law enforcement officials in limited circumstances for law enforcement purposes, such as locating a suspect, fugitive, material witness, or missing person; reporting a crime; or providing information about a victim of a crime, if under certain limited circumstance, we are unable to obtain the person’s agreement.

  • Coroners, Medical Examiners and Funeral Directors – To coroners, medical examiners or funeral directors as required by law and necessary to perform their duties.

  • Military Activity and National Security – To authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law or in connection with providing protection to the President, other authorized personnel or foreign heads of state or to conduct special investigations.

  • Correctional Facilities – To a correctional facility or law enforcement official, if you are an inmate or under custody.


Click the PDF icon to download the Patient Privacy Infographic.

bottom of page