NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE

USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

Pynenberg & Scheske DDS, S.C. (“Pynenberg & Scheske” / “We” / “Us”) is required by law to maintain the privacy of your health information. We are also required to provide you with a notice that describes our legal duties and privacy practices and your privacy rights with respect to your health information. We will follow the privacy practices described in this notice. If you have any questions about any part of this Notice or if you want more information about our privacy practices, please contact our Privacy Officer at 920-788-3542, 607 Wilson St., Little Chute, WI 54140.

We reserve the right to change the privacy practices described in this notice in the event that the practices need to be changed to follow the law. We will make the new notice provisions effective for all the protected health information that we maintain. If we change our privacy practices, we will have them available upon request. This notice will also be posted at the location of service. How We May Use or Disclose Your Health Information for Treatment, Payment or Health Care Operations

The following categories describe the ways that we may use and disclose your health

information. For each type of use and disclosure, we will explain what we mean and present some examples. Examples are for illustrative purposes only.

Treatment. We may use or disclose your health care information in the provision,

coordination, or management of your health care. Our communications to you may be by

telephone, cell phone, email, patient portal, mail, or text. For example, we may use your

information to call and remind you of an appointment or to refer your care to another dentist. If another provider requests your health information and they are not providing care and treatment to you, we will request an authorization from you before providing your information.

Payment. We may use or disclose your health care information to obtain payment for your

health care services. For example, we may use your information to send a bill for your health care services to your insurer.

Health Care Operations. We may use or disclose your health care information for activities relating to the evaluation of patient care, evaluating the performance of health care providers, business planning, and compliance with the law. For example, we may use your information to determine the quality of care you received when you received treatment. If the activities require disclosure outside of our health care organization, we will request your authorization before disclosing that information.

How We May Use or Disclose Your Health Information Without Your Written Authorization

The following categories describe ways that we may use and disclose your health information without your authorization. For each type of use and disclosure, we will explain what we mean and present some examples, which are for illustrative purposes only.

1. Required by Law. We may use and disclose your health information when that use or

disclosure is required by law. For example, we may disclose health information to report

child abuse or to respond to a court order.

2. Public Health. We may release your health information to local, state, or federal public

health agencies subject to the provisions of applicable state and federal law for

reporting communicable diseases, aiding in the prevention or control of certain

diseases, and reporting problems with products and reactions to medications to the

Food and Drug Administration.

3. Victims of Abuse, Neglect, or Violence. We may disclose your information to a

government authority authorized by law to receive reports of abuse, neglect, or

violence relating to children or the elderly.

4. Health Oversight Activities. We may disclose your health information to health

agencies authorized by law to conduct audits, investigations, inspections, licensure, and

other proceedings related to oversight of the health care system.

5. Judicial and Administrative Proceedings. We may disclose your health information in

the course of an administrative or judicial proceeding in response to a court order.

Under most circumstances, such a request is made through a subpoena or discovery

request or involves another type of administrative order, which must meet certain

conditions for disclosure.

6. Law Enforcement. We may disclose your health information to a law enforcement

official for purposes such as identifying or locating a suspect, fugitive, or missing person,

or complying with a court order or other law enforcement purposes. Under some

limited circumstances we will request your authorization prior to permitting disclosure.

7. Coroners and Medical Examiners. We may disclose your health information to coroners

and medical examiners. For example, this may be necessary to determine a cause of

death.

8. Research. Under certain circumstances, and only after a special approval process, we

may use and disclose your health information to help conduct medical research, which

may involve an assessment of how well a drug is working or whether a certain

treatment is working better than another.

9. To Avert a Serious Threat to Health of Safety. We may disclose your health information in a very limited manner to appropriate persons to prevent a serious threat to the health or safety of a particular person or the general public. Disclosure is usually limited to law enforcement personnel who are involved in protecting public safety.

10. Specialized Government Functions. Under certain and very limited circumstances, we

may disclose your health care information for military, national security, or law

enforcement custodial situations.

11. Workers’ Compensation. Both state and federal law allow the disclosure of your health

care information that is reasonably related to a worker’s compensation injury to be

disclosed without your authorization. These programs may provide benefits for work-

related injuries or illness.

12. Health Information. We may use or disclose your health information to provide

information to you about treatment alternatives or other health related benefits and

services that may be of interest to you.

When We Are Required to Obtain an Authorization to Use or Disclose Your Health Information Except as described in this Notice of Privacy Practices, we will not use or disclose your health information without written authorization from you. For example, uses and disclosures made for the purpose of marketing and the sale of protected health information require your

authorization. If you do authorize us to use or disclose your health information for another

purpose, you may revoke your authorization in writing at any time. If you revoke your

authorization, we will no longer be able to use or disclose health information about you for the reasons covered by your written authorization, though we will be unable to take back any disclosures we have already made with your permission.

Your Health Information Rights

1. Inspect and Copy Your Health Information. You have the right to inspect and obtain a

copy of your health care information. You have the right to request that the copy be

provided in an electronic form or format (e.g., PDF saved onto a flash drive). If the form

and format are not readily producible, then we will work with you to provide it in a

reasonable electronic form or format. Your request for inspection or access must be

submitted in writing to our Privacy Officer at 607 Wilson St., Little Chute, WI 54140. 

In addition, we may charge you a reasonable fee to cover our expenses for copying your

health information.

2. Request to Correct Your Health Information. You have a right to request that we amend

your health information that you believe is incorrect or incomplete. For example, if you

believe the date of a treatment is incorrect; you may request that the information be

corrected. We are not required to change your health information, and if your request is

denied, we will provide you with information about our denial and how you can disagree

with the denial. To request an amendment, you must make you request in writing to our

Privacy Officer at 607 Wilson St., Little Chute, WI 54140. You must also provide a reason for your request.

3. Request Restrictions on Certain Uses and Disclosures. You have the right to request

restrictions on how your health information is used or to whom your information is

disclosed, even if the restriction affects your treatment or our payment or health care

operation activities. However, we are not required to agree in all circumstances to your

requested restrictions, except in the case of a restriction of disclosure to a health plan if the

disclosure is for the purpose of carrying out payment or health care operations and is not

otherwise required by law and the protected health information pertains solely to a health

care item or service for which you, or the person other than the health plan on your behalf, has paid us in full. If you would like to make a request for restrictions, you must submit your

request in writing to our Privacy Officer at 607 Wilson St., Little Chute, WI 54140. A

restriction cannot be applied to your health information that has already been disclosed.

4. Receive Confidential Communications of Health Information. You have the right to

request that we communicate your health information to you in different ways or places.

For example, you may wish to receive information about your health status in a special,

private room or through a written letter sent to a private address. We must accommodate

reasonable requests. To request specific confidential communications, you must submit

your request in writing to our Privacy Officer at 607 Wilson St., Little Chute, WI 54140.

5. Receive A Record of Disclosures of Your Health Information. You have the right to request

a list of the disclosures of your health information that we have made in compliance with federal and state law. This list will include the date of each disclosure, who received the

disclosed health information, a brief description of the health information disclosed, and why the disclosure was made. For some types of disclosures, the list will also include the date and time the request for disclosure was received and the date and time the disclosure was made. For example, you may request a list that indicates all the disclosures we have made from your health care record in the past six months. To request this accounting of disclosures, you must submit your request in writing to our Privacy Officer at 607 Wilson St., Little Chute, WI 54140. We must comply with your request for a list within 60 days, unless you agree to a 30-day extension, and we may not charge you for the list, unless you request such list more than once per year.

6. Obtain A Paper Copy of This Notice. Upon your request, you may at any time receive a

paper copy of this Notice, even if you earlier agreed to receive this notice electronically. To

obtain a paper copy of this Notice, send your written request to our Privacy Officer at 607

Wilson St., Little Chute, WI 54140. This Notice is also available on our website at

www.dentistlittlechutewi.com

7. Notified of a Breach. We are required by law to maintain the privacy of protected health

information and provide you with notice of our legal duties and privacy practices with

respect to protected health information and to notify you following a breach of unsecured

protected health information that qualifies under the federal healthcare privacy rules.

8. Complaint. If you believe your privacy rights have been violated, you may file a complaint

with our Privacy Officer at 607 Wilson St., Little Chute, WI 54140, who will provide you with any needed assistance. We request that you file your complaint in writing so that we may better assist in the investigation of your complaint. You may also file a complaint with the Secretary of the Department of Health and Human Services (DHHS). There will be no

retaliation against you in any way for filing a complaint. 

If you have any questions or concerns regarding your privacy rights or the information in this notice, please contact our Privacy Officer at 920-788-3542, or 

607 Wilson St., Little Chute, WI 54140.

Effective Date of This Notice: April 1, 2024