OMNIBUS RULE HIPAA NOTICE OF PRIVACY PRACTICES

‍Facility Information

Legal Entity Practice Name:
Elmbrook Family Dental Partners, S.C.

Mailing Address:
595 North Barker Road, Suite 200
Brookfield, WI 53045

Effective Date:
February 16, 2026

IMPORTANT NOTICE

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

For purposes of this Notice:

• “We,” “our,” and “us” refer to the health care facility listed above.
• “You” and “your” refer to our patients or their authorized legal representatives.

We are committed to protecting the privacy of your Protected Health Information (PHI). We comply with the Health Insurance Portability and Accountability Act (HIPAA), its regulations, and all amendments, including the 2026 revisions concerning Substance Use Disorder (SUD) treatment information under 42 CFR Part 2.

OUR RESPONSIBILITIES

We are required to:

• Maintain the privacy of your PHI, including SUD information with additional protections under 42 CFR Part 2
• Provide you with this Notice of our legal duties and privacy practices
• Notify you if a breach of unsecured PHI occurs
• Follow the terms of this Notice

HOW WE MAY USE AND DISCLOSE YOUR PHI (WITHOUT WRITTEN AUTHORIZATION)

Treatment

We may share your PHI with other health care professionals treating you.
Example: Sending x-rays to a specialist for consultation.

Payment

We may use and share your PHI to bill and receive payment.
Example: Submitting claims to your dental plan.

Health Care Operations

We may use PHI to run and improve our practice and contact you when needed.
Examples: Quality reviews, audits, customer service.

Public Health & Safety

We may disclose PHI to:

• Report abuse or neglect
• Prevent serious threats to health or safety
• Support public health reporting or product recalls

Health Oversight & Law Enforcement

We may disclose PHI:

• To oversight agencies
• For law enforcement purposes
• In response to court orders, subpoenas, or legal processes

Research

We may use or disclose PHI for research under approved conditions or with your authorization.

Workers’ Compensation & Government Functions

We may disclose PHI as required for workers’ compensation or specialized government functions.

Business Associates

We may share PHI with third-party service providers under contracts requiring confidentiality.

USES & DISCLOSURES REQUIRING YOUR AUTHORIZATION

We must obtain your written permission for:

• Most uses of psychotherapy notes (if applicable)
• Marketing communications or sale of PHI
• Any uses not described in this Notice

YOUR RIGHTS REGARDING YOUR PHI

Right to Access

You may request copies of your records (electronic or paper).
A reasonable fee may apply.

Right to Amend

You may request corrections to your records.
We will respond within 60 days.

Right to Request Restrictions

You may request limits on how PHI is used or disclosed.
We must honor restrictions if you pay in full out-of-pocket and request no disclosure to your health plan.

Right to Confidential Communications

You may request contact in a specific way or location.

Right to an Accounting of Disclosures

You may request a list of disclosures made in the past six years.

Right to a Paper Copy

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

Right to a Personal Representative

A legally authorized person may act on your behalf.

OUR DUTIES

• Maintain the privacy and security of your PHI
• Notify you promptly of any breach
• Follow this Notice and provide a copy
• Obtain written permission for uses not described here

You may revoke your authorization at any time in writing.

SPECIAL NOTICE: SUBSTANCE USE DISORDER (SUD) RECORDS (42 CFR PART 2)

If applicable, SUD records receive additional protections:

• Generally cannot be used or disclosed without your written consent
• Cannot be used against you in legal proceedings without consent or a court order
• Consent may be revoked as permitted by law

This Notice may be combined with a Part 2 Patient Notice if all requirements are met.

FUNDRAISING COMMUNICATIONS

If we contact you for fundraising:

• You will have the option to opt out
• SUD records will not be used without your written consent

QUESTIONS & COMPLAINTS

You may file a complaint with:

U.S. Department of Health & Human Services
Office for Civil Rights
200 Independence Ave., SW
Washington, DC 20201
Phone: 877-696-6775

OR contact our Privacy Officer:

Name: Dr. Eric Taibl
Facility: Elmbrook Family Dental Partners, S.C.
Address: 595 North Barker Road, Suite 200, Brookfield, WI 53045
Phone: 262-923-7075
Fax: 262-439-8619
Email: efdwest@elmbrookfamilydental.com

We will not retaliate against you for filing a complaint.

ACKNOWLEDGMENT

You will be asked to sign an acknowledgment confirming receipt of this Notice.

NOTE

• This Notice is written in plain language
• It is available in our office and on our website
• Copies are available upon request
• We will update this Notice if our privacy practices change

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