Allison Jung Family Dentistry, PLLC

Notice of Privacy Practices

Effective Date: February 1, 2018

Revised: January 28, 2026

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We are required by law to maintain the privacy of your protected health information (PHI), provide you with notice of our legal duties and privacy practices, and notify you following a breach of unsecured PHI. We must follow the privacy practices described in this Notice while it is in effect.

We reserve the right to change our privacy practices and the terms of this Notice at any time, as permitted by law. When changes are made, a new Notice will be posted prominently in our office, and copies will be available upon request.

You may request a copy of this Notice at any time. For more information about our privacy practices, please contact us using the information at the end of this Notice.

How We May Use and Disclose Health Information About You

We may use or disclose your PHI for the following purposes:

1. Treatment

We may use or disclose your PHI to provide, coordinate, or manage your care.

Example: Sharing relevant information with a specialist involved in your treatment.

2. Payment

We may disclose PHI to obtain payment for services, including billing, claims management, and eligibility checks.

Example: Submitting claims to your dental insurance plan.

3. Healthcare Operations

We may use PHI for activities that support the operation of our practice, such as quality improvement, staff training, and licensing.

4. Individuals Involved in Your Care

We may disclose PHI to friends, family members, or others involved in your care or payment. If someone is legally authorized to make decisions for you, we will treat that person the same as you regarding PHI.

5. Disaster Relief

We may disclose PHI to assist in disaster relief efforts.

6. Required by Law

We may disclose PHI when required by federal, state, or local law.

7. Public Health Activities

These include reporting to public health authorities to:

• Prevent or control disease, injury, or disability
• Report child abuse or neglect
• Report adverse reactions to medications or device problems
• Notify individuals of recalls
• Notify individuals who may have been exposed to a disease
• Report suspected abuse, neglect, or domestic violence

8. National Security & Law Enforcement

We may disclose PHI to:

• Military authorities for Armed Forces personnel
• Federal officials for lawful intelligence or national security activities
• Correctional institutions regarding individuals in custody
• Law enforcement as required by law or court orders

9. Secretary of Health and Human Services

We must provide PHI when requested for compliance investigations.

10. Worker’s Compensation

We may disclose PHI as authorized by worker’s compensation laws.

11. Health Oversight Activities

These include audits, investigations, inspections, and licensure activities.

12. Judicial & Administrative Proceedings

We may disclose PHI in response to court or administrative orders or certain legal processes.

13. Research

We may disclose PHI for approved research projects with appropriate privacy safeguards.

14. Coroners, Medical Examiners & Funeral Directors

We may disclose PHI as necessary for identification, determining cause of death, or other duties.

15. Fundraising

We may contact you regarding fundraising activities. You may opt out at any time.

16. Substance Use Disorder (SUD) Treatment Information

PHI from a Part 2 Program will be used or disclosed only as permitted by your consent or as allowed by law. Part 2 information cannot be used in legal proceedings without your consent or a qualifying court order.

Other Uses and Disclosures

Your written authorization is required for:

• Psychotherapy notes
• Marketing uses
• Sale of PHI
• Any other uses/disclosures not described in this Notice

You may revoke your authorization at any time in writing, except where action has already been taken.

Your Health Information Rights

1. Right to Access

You may inspect or obtain copies (paper or electronic) of your PHI. Fees may apply as permitted by law.

2. Right to Request an Accounting of Disclosures

You may request a list of certain disclosures made during the previous six years. Additional requests within 12 months may incur a fee.

3. Right to Request Restrictions

You may request limits on how we use or disclose your PHI. We are not required to agree, except when you pay out of pocket in full and request that we not disclose that information to your health plan.

4. Right to Request Confidential Communications

You may request communication via alternative methods or locations. We will accommodate reasonable requests.

5. Right to Request Amendment

If you believe your PHI is incorrect or incomplete, you may request an amendment. If we deny your request, we will explain why.

6. Right to Receive Notice of a Breach

You will be notified of any breach of your unsecured PHI as required by law.

7. Right to a Paper Copy

You may request a paper copy of this Notice at any time.

Questions and Complaints

If you have questions or concerns about our privacy practices, or if you believe your privacy rights have been violated, you may contact us using the information below.

You may also file a complaint with the U.S. Department of Health and Human Services. We will provide the appropriate address upon request.

We will not retaliate against you for filing a complaint.

Contact Information

Privacy Official: Destiny N.

Phone: 970-484-4850

Fax: 970-484-2757

Address: 1927 Wilmington Dr, Unit 202, Fort Collins, CO 80528

Email: info@ajfamilydentistry.com