New patient special $159 (exam, x-rays, and regular cleaning included)
Shine Dental is required, by law, to maintain the privacy and confidentiality of our patients’
protected health information. We take this duty very seriously. We are also bound by law to
provide our patients with notice of our legal duties and privacy practices with respect to their
protected health information. That is part of the purpose of this notice.
Disclosure of Patient Health Care Information
In connection with treatment, we may disclose patient health care information to other
healthcare professionals within our practice for the purpose of treatment, payment or
We may disclose patient health information to insurance providers for the purpose of
payment or health care operations.
We may disclose patient health information as necessary to comply with State Workers’
We may disclose patient health information to notify or assist in notifying a family
member, or another person responsible for patient care about patient medical condition
or in the event of an emergency.
As required by law, we may disclose patient health information to public health
authorities for purposes related to: preventing or controlling disease, injury or disability,
reporting child abuse or neglect, reporting domestic violence, reporting to the Food and
Drug Administration problems with products and reactions to medications, and reporting
disease or infection exposure.
We may disclose patient health information in the course od any administrative or
We may disclose patient health information to coroners or medical examiners.
We may disclose information to organizations involved in procuring, banking, or
transplanting organs and tissues.
We may disclose patient health information to researchers conducting research that has
been approved by an Institutional Review Board.
It may be necessary to disclose patient health information to appropriate persons in
order to prevent or lessen a serious and imminent threat to the health or safety of a
particular person or to the general public.
We may disclose patient health information for military, national security, prisoner, and
government benefits purposes. In the event that Dr. Sharon Chun/ Shine Dental is sold
or merged with another organization, patient health information/record will become the
property of the new owner.
Dr. Sharon Chun D.D.S
701 W. Golf Rd #1 Mt Prospect IL 60056
Patient Health Information Rights
You have the right to request restrictions on certain uses and disclosures of your or your
child’s patient health information. Please be advised, however, that Dr. Sharon Chun/
Shine Dental is not required to agree to the restriction that you requested.
You have the right to have your child’s health information received or communicated
through an alternative method or sent to an alternative location other than the usual
method of communication or delivery, upon request.
You have the right to inspect and copy your or your child’s patient health information.
You have a right to request Dr. Sharon Chun/ Shine Dental amend your or your child’s
protected health information.
Please be advised, however, that Dr. Sharon Chun/ Shine Dental is not required to
agree to amend patient protected health information. If your request to amend patient
health information has been denied, you will be provided with an explanation of our
denial reason(s) and information about how you can disagree with the denial.
You have a right to receive an accounting of disclosures of your or your child’s protected
health information made by Dr. Sharon Chun/ Shine Dental.
You have a right to a paper copy of this Notice of Privacy Practices at any time upon
Dr. Sharon Chun/ Shine Dental reserves the right to amend this Notice of Privacy
Practices at any time in the future and will make the new provisions effective for all
information that it maintains. Until such amendment is made, Dr. Sharon Chun/ Shine
Dental is required by law to comply with this Notice.
If you have questions about any part of this notice or if you want more information about
patient privacy rights, please contact: Dr. Sharon Chun by calling this office at 224-999-
9000. If Dr. Sharon Chun is not available, you may make an appointment for a personal
conference in person or by telephone.
If you wish, you may submit a formal complaint to:
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, DC 20201
Thank you for reading this notice.