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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

healthcare operations.

 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’

Compensation Laws.

 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

judicial proceeding.

 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.

SHINE DENTAL

Dr. Sharon Chun D.D.S

701 W. Golf Rd #1 Mt Prospect IL 60056

P:224-999-900 F:847-258-4874

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

request.

 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:

DHHS

Office of Civil Rights

200 Independence Avenue, S.W.

Room 509F

HHH Building

Washington, DC 20201

Thank you for reading this notice.