HIPAA Compliant | Effective Date: July 1, 2025
3340 Robinwood Rd #140, Gastonia, NC 28054 | (704) 755-1900
As the parent or legal guardian of a minor patient, you have rights regarding your child's protected health information (PHI). This Notice applies to all records of care created or received by South Gaston Pediatric Dentistry.
South Gaston Pediatric Dentistry is a pediatric dental practice located at 3340 Robinwood Rd #140, Gastonia, NC 28054. We are a "covered entity" under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its implementing regulations, and we are required by law to maintain the privacy of your child's protected health information (PHI), provide you with this Notice of our legal duties and privacy practices, and abide by the terms of the Notice currently in effect.
This policy applies to all patients of South Gaston Pediatric Dentistry, all staff members, contractors, volunteers, and trainees who work with our practice.
Protected Health Information (PHI) includes any individually identifiable health information we collect, create, or receive in connection with your child's dental care. This includes, but is not limited to:
Your child's name, address, date of birth, and Social Security number
Dental and medical records, diagnoses, and treatment plans
Appointment history and clinical notes
X-rays, photographs, and other diagnostic images
Health insurance information and claims
Billing records and payment information
Any other information that could identify your child in connection with their health
We use and disclose your child's PHI in the following ways:
3.1 Treatment
We use and share your child's PHI to provide, coordinate, and manage their dental care. This includes sharing information with other healthcare providers involved in their treatment, such as specialists, oral surgeons, orthodontists, or physicians. For example, we may share X-rays or clinical notes with a referred specialist.
3.2 Payment
We use and disclose PHI to obtain payment for services rendered. This includes submitting claims to your dental insurance carrier, verifying benefits, obtaining prior authorization, and collecting payment. We may share relevant information with your insurance company to process claims.
3.3 Healthcare Operations
We use PHI for our internal business operations, including:
Quality assessment and improvement activities
Staff training and education
Compliance audits and legal reviews
Business planning and management
Customer service and patient satisfaction activities
3.4 Appointment Reminders
We may contact you to remind you of your child's scheduled appointments or to notify you of treatment options that may be of benefit. We may do this via phone call, text message, email, or mail. You may request that we contact you in a specific manner.
3.5 Other Uses and Disclosures Permitted Without Your Authorization
In certain situations, we may use or disclose your child's PHI without your written authorization, including:
As required by law: We will disclose PHI when required to do so by federal, state, or local law.
Public health activities: To public health authorities for purposes such as reporting disease, injury, vital statistics, or FDA-regulated product concerns.
Child abuse or neglect: We are required by North Carolina law to report suspected child abuse or neglect to appropriate authorities. This is a mandatory reporting obligation.
Health oversight activities: To government agencies for audits, inspections, licensure, and oversight of the healthcare system.
Judicial and administrative proceedings: In response to a court order, subpoena, or discovery request, under certain conditions.
Law enforcement: Under limited circumstances, such as to identify or locate a suspect, or to report a crime on our premises.
Serious threats to health or safety: To prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
Workers' compensation: To the extent authorized and necessary to comply with workers' compensation or similar programs.
Coroners and medical examiners: To identify a deceased person or determine cause of death.
Organ and tissue donation: To organizations that handle organ procurement, transplantation, or tissue banking.
Research: Under certain conditions and with proper safeguards, as permitted by HIPAA.
Business associates: To vendors and service providers ("business associates") who assist us in operating our practice, such as billing services, IT support, and record storage, provided they agree in writing to protect the privacy of your child's PHI.
The following uses and disclosures of your child's PHI require your written authorization before we proceed:
Most uses and disclosures of psychotherapy notes (if applicable)
Uses and disclosures of PHI for marketing purposes
Sale of PHI
Any other use or disclosure not described in this Notice
If you provide written authorization for any of the above, you may revoke that authorization at any time by submitting a written request to our Privacy Officer. Revocation is not effective for actions already taken in reliance on your prior authorization.
As the parent or legal guardian of a minor patient, you have the following rights:
5.1 Right to Inspect and Copy
You have the right to inspect and obtain a copy of your child's dental records and other PHI that we maintain in a designated record set. To request access, please submit a written request to our Privacy Officer. We may charge a reasonable fee for copying and postage. We will respond to your request within 30 days. In limited circumstances, we may deny access and you may request a review of that denial.
5.2 Right to Amend
If you believe that information in your child's record is incorrect or incomplete, you have the right to request that we amend it. Submit a written request to our Privacy Officer explaining the reason for the requested amendment. We may deny the request if the information was not created by us, is not part of the designated record set, or is accurate and complete. If denied, you may submit a statement of disagreement, which will be included in your child's record.
5.3 Right to an Accounting of Disclosures
You have the right to receive a written accounting of certain disclosures of your child's PHI that we have made in the past six years (excluding disclosures made for treatment, payment, healthcare operations, or disclosures you authorized). Submit a written request to our Privacy Officer. The first accounting in any 12-month period is free; subsequent requests may incur a reasonable fee.
5.4 Right to Request Restrictions
You have the right to request that we restrict how we use or disclose your child's PHI for treatment, payment, or healthcare operations. We are not required to agree to your request unless the restriction is to a health plan regarding a service you paid for in full out-of-pocket. If we agree to a restriction, we will comply unless the information is needed to provide emergency treatment. Submit restriction requests in writing to our Privacy Officer.
5.5 Right to Request Confidential Communications
You may request that we communicate with you about your child's health information in a specific way or at a specific location. For example, you may ask that we only contact you at a certain phone number or address. We will accommodate reasonable requests. Submit your request in writing or verbally to our front desk staff.
5.6 Right to a Paper Copy of This Notice
You have the right to obtain a paper copy of this Notice at any time, even if you have previously agreed to receive the Notice electronically. Please ask any staff member or contact our Privacy Officer.
5.7 Right to Be Notified of a Breach
We are required by law to notify you if there is a breach of your child's unsecured PHI. Notification will be provided without unreasonable delay and within 60 days of discovery of the breach, and will include a description of what occurred, what information was involved, what steps you should take to protect yourself, and what we are doing to investigate and mitigate the breach.
5.8 Rights of Minor Patients
In most cases, parents or legal guardians have full access to a minor child's dental records. However, there are limited circumstances under North Carolina law and HIPAA in which a minor may have the right to control certain aspects of their own health information. We will advise you if such a situation arises. When a patient reaches the age of 18, they become the legal decision-maker for their own health information.
South Gaston Pediatric Dentistry is required by law to:
Maintain the privacy of your child's PHI
Provide you with this Notice of our privacy practices
Follow the terms of the Notice currently in effect
Notify you following a breach of unsecured PHI
Not use or disclose your child's PHI other than as described in this Notice or as authorized by you
We reserve the right to change this Notice and our privacy practices at any time, provided such changes are permitted by law. Changes will apply to PHI we already have on file as well as information received in the future. If we make a material change to this Notice, we will post the revised Notice in our office and on our website, and provide a copy to you upon request.
7.1 Information We Collect Online
If you contact us through our website, request an appointment online, or submit any forms electronically, we may collect the information you provide, including your name, contact information, and the nature of your inquiry. We do not collect PHI through our website outside of secure, HIPAA-compliant patient portals or forms.
7.2 Cookies and Tracking
Our website may use cookies and similar tracking technologies to improve your browsing experience and analyze site traffic. Cookies do not contain PHI. You may disable cookies through your browser settings; however, some features of our website may not function properly as a result.
7.3 Third-Party Links
Our website may contain links to third-party websites. We are not responsible for the privacy practices or content of those websites. We encourage you to review the privacy policies of any third-party sites you visit.
7.4 Google and Advertising
We may use Google Analytics or similar services to understand how visitors use our website. This data is aggregated and does not identify individual users. We do not use advertising platforms that link online activity to your child's PHI.
South Gaston Pediatric Dentistry takes the security of your child's health information seriously. We implement appropriate administrative, physical, and technical safeguards to protect PHI against unauthorized access, use, or disclosure, including:
Encrypted electronic health records and data transmission
Password-protected systems with role-based access controls
Staff training on HIPAA privacy and security requirements
Locked physical file storage for paper records
Secure disposal of records containing PHI
Regular review and updating of security policies and procedures
Business Associate Agreements with all vendors who access PHI
In some cases, North Carolina state law provides greater privacy protections for health information than HIPAA. Where state law is more protective, we will comply with the more stringent state requirements. Areas where North Carolina law may provide additional protections include, but are not limited to:
Mental health and substance abuse treatment records
HIV/AIDS-related information
Genetic information
Certain communications between minors and healthcare providers
We will comply with all applicable state and federal laws governing the privacy of health information.
Contact Our Privacy Officer
To exercise any of your rights described in this Notice, to request a copy of this Notice, or to ask questions about our privacy practices, please contact:
Privacy Officer
South Gaston Pediatric Dentistry
3340 Robinwood Rd #140, Gastonia, NC 28054
Phone: (704) 755-1900
Filing a Complaint
If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S. Department of Health and Human Services, Office for Civil Rights. You will not be penalized or retaliated against in any way for filing a complaint.
U.S. Department of Health and Human Services, Office for Civil Rights:
200 Independence Avenue, S.W., Washington, D.C. 20201
Toll-Free: 1-877-696-6775 | Website: www.hhs.gov/ocr/privacy
South Gaston Pediatric Dentistry reserves the right to revise or update this Privacy Policy and Notice of Privacy Practices at any time. When we make a material change, we will post the updated Notice in our office waiting area, make it available at the front desk, and publish it on our website. The effective date of the current version is noted at the top of this document. We encourage you to review this Notice periodically.
By receiving dental services from South Gaston Pediatric Dentistry, you acknowledge that you have been provided with or offered a copy of our Notice of Privacy Practices. You are not required to sign this acknowledgment to receive treatment; however, your signature helps us document that we provided you with this Notice.
Parent / Legal Guardian Name (Print): _______________________________________________
Patient (Child) Name: __________________________________________________________________
Relationship to Patient: ________________________________________________________________
Signature: _____________________________________________ Date: ___________________
If you were unable to sign this acknowledgment, please describe why: ___________________________
___________________________________________________________________________________________
Parent / Legal Guardian Name (Print): ______________________________________________
Patient (Child) Name: ______________________________________________
Relationship to Patient: ______________________________________________
Signature: _____________________________________________
Date: ___________________
If you were unable to sign this acknowledgment, please describe why: ___________________________
___________________________________________________________________________________________
South Gaston Pediatric Dentistry | 3340 Robinwood Rd #140, Gastonia, NC 28054 | (704) 755-1900
Notice of Privacy Practices | Effective: July 1, 2025 | This document satisfies the HIPAA Notice of Privacy Practices requirement (45 C.F.R. § 164.520)