Patient Information

Appointments with a faculty provider are generally the same length of time and cost as appointments in private practice. Appointments with faculty are generally shorter and less frequent, but more expensive than appointments with graduate student or predoctoral student providers.

Appointments with graduate student providers are generally shorter than those with a predoctoral student provider, but longer than those with a faculty provider. They are less expensive than appointments with a faculty member, but more expensive than appointments with a predoctoral student provider.

Appointments with predoctoral student providers are often the least expensive, but are also the longest (generally three hours), as the students’ work is carefully check by a faculty member, and most frequent (every month).

Emergencies happen. Simply call (919) 537-3737 to cancel your appointment 48 hours ahead of your appointment.

Patients who do not show up for appointments may be charged a cancellation fee.

Patients who repeatedly break or cancel appointments without at least 48 hours notice may be dismissed from Carolina Dentistry at the discretion of the dental provider managing the patient’s care.

Payment methods and times of payment vary by provider level.

Patients are encouraged to discuss payment options and questions with Patient Business Services at (919) 537-3940.

If you feel that you have not received fair treatment you may report your concerns via MyChart.

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.

Effective: March 10, 2003 | Revision Effective: May 1, 2018

If you have any questions or requests regarding the privacy of your medical
information, please contact:
UNC-CH HIPAA Privacy Officer
Campus Box #1150,
440 W. Franklin St.,
Chapel Hill, NC 27599
(919) 962-6332
privacy@unc.edu

A. We have a legal duty to protect health information about you.

We are required by law to protect the privacy of health information about you and that can be identified with you, which we call “protected health information,” or “PHI” for short. We must give you notice of our legal duties and privacy practices
concerning PHI:

• We must protect PHI that we have created or received about: your past, present, or future health condition; health care we provide to you; or payment for your health care.
• We must explain how we protect PHI about you.
• We must explain how, when and why we use and/or disclose PHI about you.
• We may only use and/or disclose PHI as we have described in this Notice.

This Notice describes the types of uses and disclosures that we may make and gives you some examples.

In addition, we may make other uses and disclosures which occur as a byproduct of the permitted uses and disclosures described in this Notice. The providers participating in our “organized health care arrangement” will share PHI with each other, as necessary to carry out treatment, payment or health care operations (defined below) relating to the “organized health care arrangement.”

We are required to follow the procedures in this Notice. We reserve the right to change the terms of this Notice and to make new notice provisions effective for all PHI that we maintain by first:

• Posting the revised notice in our offices;
• Making copies of the revised notice available upon request (either at our offices or through the contact person listed in this Notice); and
• Posting the revised notice on our website, www.dentistry.unc.edu.

B. For some uses and/or disclosures of PHI about you, we will obtain your general consent; for other uses and/or disclosures of PHI about you, we will obtain your authorization; and, in some circumstances, we may use and/or disclose PHI about you without your authorization.

Federal law requires us to protect the privacy of PHI about you.

In addition, North Carolina law protects not only your rights of privacy, but also your relationship with your physician and, if applicable, your mental health provider.

State law restricts our disclosure (and that of your physician or mental health provider) of your health information in many instances. However, we may disclose your health information under State and Federal law for treatment, payment, and health care operations, with your permission, pursuant to a court order, or as otherwise may be permitted or required by law.

We will request that you sign a “general consent for treatment” form which asks for your permission to provide treatment to you and provides other information and consents. This “general consent for treatment” also asks for you to sign a statement confirming that you have received a copy of this Notice. This “general consent for treatment” is different from an “authorization” that is mentioned in other parts of this Notice.

1. North Carolina state law and Federal law allow us to use and disclose PHI about you for the purposes of: providing treatment to you, obtaining payment for those services, and for health care operations. These purposes are described below.

TREATMENT:
We need to use and disclose PHI about you to provide, coordinate or manage your health care and related services. This may include communicating with other health care providers regarding your treatment and coordinating and managing your health care with others. For example, we need to use and disclose PHI about you, both inside and outside our School, when you need a prescription, lab work, or other health care services. In addition, we need to use and disclose PHI about you when referring you to another health care provider.
EXAMPLE: A dentist, dental hygienist or student treating you may need to know if you have diabetes because diabetes may slow the healing process. If so, the dentist or dental student may contact your physician or other healthcare providers for information regarding your health. Dentists, dental students, and other healthcare providers may need to share PHI about you, both inside and outside our School, in order to coordinate different services you may need. We may also need to disclose PHI about you to people outside the School who may be involved in your healthcare.

PAYMENT:
Generally, we need to use and give medical information about you to others to bill and collect payment for the treatment and services provided to you. Before you receive scheduled services, we may need to share information about these services with your health plan(s). Sharing information allows us to ask for coverage under your plan or policy and for approval of payment before we provide the services. We may also need to share portions of medical information about you with the following:

• Billing departments;
• Collection departments or agencies, or attorneys assisting us with collections, including the State of North Carolina Office of the Attorney General;
• Insurance companies, health plans and their agents which may be responsible for payment of your health care bills;
• Consumer reporting agencies (e.g., credit bureaus); and
• Others who are responsible for your bills, such as your spouse or a guarantor of your bills, as necessary for us to collect payment.

EXAMPLE: Let’s say you have a tooth removed and replaced. We may need to give your health plans (medical and dental) information about your condition and treatment you received.

The information is given to our billing department and your health plan so we can be paid or you can be reimbursed. We may also need to send the same information to a School department that reviews your care.

If you have provided a cellular telephone number to us, we may use that number to contact you regarding billing and collections, unless you tell us otherwise.

As described more below, you may request to restrict disclosure of PHI about you to your health plan for payment purposes when the PHI pertains solely to a health care item or service for which you, or another on your behalf, have paid in full out of pocket.

HEALTH CARE OPERATIONS:
We need to use and disclose PHI in performing business activities, which we call “health care operations.”

These “health care operations” allow us to improve the quality of care we provide and reduce health care costs. In addition, we may need to disclose PHI about you for the “health care operations” of other providers involved in your care to improve the quality, efficiency and costs of their care or to evaluate and improve the performance of their providers.

Examples of the way we may need to use or disclose PHI about you for “health care operations” include the following:

• Reviewing and improving the quality, efficiency and cost of care that we provide to you and our other patients. For example, we may need to use PHI about you to develop ways to assist our health care providers and staff in deciding what dental treatment should be provided to others.
• Improving health care and lowering costs for groups of people who have similar medical or dental problems and to help manage and coordinate the care for these groups of people.
  We may need to use PHI to identify groups of people with similar medical or dental problems to give them information, for instance, about treatment alternatives, classes, or new procedures.
• Reviewing and evaluating the skills, qualifications, and performance of health care providers taking care of you.
• Providing training programs for students, trainees, health care providers or non-health care professionals (for example, billing clerks or assistants, etc.) to help them practice or improve their skills.
• Cooperating with outside organizations that assess the quality of the care we and others provide. These organizations might include government agencies or accrediting bodies such as the American Dental Association Commission on Dental Education.
• Cooperating with outside organizations that evaluate, certify or license health care providers, staff or facilities in a particular field or specialty. For example, we may need to use or disclose PHI so that one of our dental residents may become certified as having expertise in a specific field of dentistry, such as orthodontics, or to organizations which accredit our special programs such as the American Dental Association Commission on Dental Education.
• Assisting various people who review our activities. For example, PHI may be seen by dentists reviewing the services provided to you, and by accountants, lawyers, and others who assist us in complying with applicable laws.
• Planning for our organization’s future operations, and fundraising for the benefit of our organization.
• Conducting business management and general administrative activities related to our organization and the services it provides such as activities performed for risk management and legal purposes.
• Resolving grievances within our organization.
• Reviewing activities and using or disclosing PHI in the event that we sell our business, property or give control of our business or property to someone else.
• Complying with this Notice and with applicable laws.

BUSINESS ASSOCIATES:
There are some services we provide through outside individuals or companies, including vendors, contracted health care providers, offsite storage facilities, and liability insurance carriers. These individuals or companies, called “Business Associates”, are required by law to provide appropriate safeguards and procedures for privacy and security of PHI entrusted to them under the contract.

2. We may use and/or disclose PHI in some circumstances only with your authorization.

In the event we may seek to use and/or disclose PHI about you for  marketing purposes, or sell PHI about you, we will only do so after obtaining your authorization. For any other use and/or disclosure of PHI about you not otherwise described in this Notice of Privacy Practices, we will seek your authorization.

3. We may use and disclose PHI under other circumstances without your authorization or providing you with an opportunity to agree or object.

We may use and/or disclose PHI about you for a number of circumstances in which you do not have to consent, give authorization or otherwise have an opportunity to agree or
object. However, some North Carolina laws regarding specific types of treatment may provide you with more protection, and those special protections are discussed in subsection B.4 below. The circumstances in which you do not have to consent, give authorization, or otherwise have an opportunity to agree or
object, include:

• When the use and/or disclosure is required by law. For example, when a disclosure is required by federal, state or local law or other judicial or administrative proceeding.
• When the use and/or disclosure is necessary for public health activities. For example, we may disclose PHI about you if you have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition (subject to the special restrictions discussed in subsection B.5 below).
• When the disclosure relates to victims of abuse, neglect or domestic violence.
• When the use and/or disclosure is for health oversight activities.
• When the disclosure is for judicial and administrative proceedings. For example, we may disclose PHI about you in response to an order of a court or administrative tribunal.
• When the disclosure is for law enforcement purposes. For example, we may disclose PHI about you in order to comply with laws that require the reporting of certain types of wounds or other physical injuries.
• When the use and/or disclosure relates to decedents. For example, we may disclose PHI about you to a coroner or medical examiner for the purposes of identifying you should you die.
• When the use and/or disclosure relates to research. Under certain circumstances, we may disclose PHI about you for research.
• When the use and/or disclosure is to protect against a serious threat to health or safety. For example, we may disclose PHI about you to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
• When the use and/or disclosure relates to specialized government functions. For example, we may disclose PHI about you if it relates to military and veterans’ activities, national security and intelligence activities, protective services for the President, and medical suitability or determinations of the Department of State.
• When the use and/or disclosure relates to correctional institutions and in other law enforcement custodial situations. For example, in certain circumstances, we may disclose PHI about you to a correctional institution having lawful custody of you.
• When the use and/or disclosure is required under North Carolina’s laws regarding workers’ compensation. For example, in certain circumstances, we may disclose PHI about you to your employer and your employer’s workers’ compensation carrier regarding a work-related injury or illness.

4. You can object to certain uses and disclosures.

Unless you object, we may use or disclose PHI about you in the following circumstances (subject to the special restrictions discussed in subsection B.5 below):

• We may share with a family member, relative, friend or other person identified by you, PHI directly related to that person’s involvement in your care or payment for your care. We may share with a family member, authorized representative or other person responsible for your care PHI necessary to notify such individuals of your location, general condition or death.
• We may share with a public or private agency (for example, American Red Cross) PHI about you for disaster relief purposes. Even if you object, we may still share the PHI about you, if necessary for the emergency circumstances. If you would like to object to our use or disclosure of PHI about you in the above circumstances, please call our contact person listed on the cover page of this Notice.

5. You may have additional rights under other laws.

Some North Carolina laws provide you with more protection for specific types of information than federal laws protecting the privacy of medical information about you, and where applicable, we will follow the requirements of those state laws. Some of these laws are discussed in other sections above.

In addition, the following laws may apply to our treatment of you:

• If you have one of several specific communicable diseases (for example, tuberculosis, syphilis or HIV/AIDS), information about your disease will be treated as confidential, and will be disclosed without your written permission only in limited circumstances. We may not need to obtain your permission to report information about your communicable disease to State and local officials or to otherwise use or release information in order to protect against the spread of the disease.
• In connection with its supervision of our services, the North Carolina Department of Health and Human Services may make inspections of our operations and may review health information of our patients. Before we release any health information relating to you to this agency, we will provide you with written notice and the opportunity to object to this release.
• North Carolina law generally requires that we obtain your written consent before we may disclose health information related to your mental health, developmental disabilities, or substance abuse services. There are some exceptions to this requirement. We can disclose this health information to members of our workforce, our professional advisors, and to agencies or individuals that oversee our operations or that help us carry out our responsibilities in serving you. We also may disclose information to the following people: (i) a health care provider who is providing emergency medical services to you and (ii) to other mental health, developmental disabilities, and substance abuse facilities or professionals when necessary to coordinate your care or treatment. If we determine that there is an imminent threat to your health or safety, or the health or safety of someone else, we may disclose information about you to prevent or lessen the threat.
  We also will release information about you if the law requires us to do so, for example, when a court orders disclosure, when we suspect abuse or neglect of a child or disabled adult, and when one of our providers or students believes that a client has a communicable disease or is infected with HIV and is not following safety measures. If we believe it is in your best interests, we may disclose information about you for a guardianship or involuntary commitment proceeding that involves you.
• If we suspect that a child is abused or neglected, state law requires us to report the abuse or neglect to the Department of Social Services. We will disclose information about you if a court orders us to do so. If you commit a crime, or threaten to commit a crime, on the premises of our program or against our program personnel, we may report information about the crime or threat to law enforcement officers.
• Certain professional licensing rules and ethical standards may provide more protection for health information, and where applicable, we will follow those rules and standards.

6. We may contact you to provide appointment reminders. We may use and/or disclose PHI to contact you to provide a reminder to you about an appointment you have for dental care.

 7. We may contact you with information about treatment, services, products or health care providers. We may use and/or disclose PHI to manage or coordinate your healthcare. This may include telling you about treatments, services, products and/or other healthcare providers. We may also use and/or disclose PHI to give you gifts of a small value. EXAMPLE: If you are diagnosed with gum disease, we may tell you about related services that may be of interest to you.

8. We may contact you for fundraising activities.

We may use and/or disclose PHI about you, including disclosure to a foundation, to contact you to raise money for the School and its operations.

We may release treating provider(s), department(s) of service, and outcome(s) information related to treatment or services you received at the School, your insurance status, and demographic information about you (including addresses, contact information, age, date of birth, and gender), as well as the dates you received treatment or services from us.

Every fundraising communication from us to you will provide you with an opportunity and means to opt out of receiving such communications in the future. You may opt out of receiving fundraising communications at this time by notifying the HIPAA Privacy Liaison at 919-537-3588.

** ANY OTHER USE OR DISCLOSURE OF PHI ABOUT YOU REQUIRES YOUR WRITTEN AUTHORIZATION **

Under any circumstances other than those listed above, we will ask for your written authorization before we use or disclose PHI about you. If you sign a written authorization allowing us to disclose PHI about you in a specific situation, you can later cancel your authorization in writing by contacting our HIPAA Privacy Liaison.

If you cancel your authorization in writing, we will not disclose PHI about you after we receive your cancellation, except for disclosures which were being processed before we received your cancellation.

C. You have several rights regarding PHI about you. 

1. You have the right to request restrictions on uses and disclosures of PHI about you.

You have the right to request that we restrict the use and disclosure of PHI about you. We are not required to agree to your requested restrictions in most circumstances.

However, even if we agree to your request, in certain situations your restrictions may not be followed. These situations include emergency treatment, disclosures to the Secretary of the Department of Health and Human Services, and uses and disclosures described in subsection B.2 of the previous section of this Notice.

We must agree to your request to restrict disclosure of PHI about you which pertains solely to a health care item or service for which you, or another on your behalf, have paid in full out of pocket, if such disclosure is to a health plan for the purpose of carrying out payment or health care operations.

You may request a restriction by contacting the HIPAA Privacy Liaison at 919-537-3588.

2. You have the right to request different ways to communicate with you.

You have the right to request how and where we contact you about PHI. For example, you may request that we contact you at your work address or phone number or by email. Your request must be in writing.

We must accommodate reasonable requests, but, when appropriate, may condition that accommodation on your providing us with information regarding how payment, if any, will be handled and your specification of an alternative address or other method of contact. You may request alternative communications by contacting the HIPAA Privacy Liaison at 919-537-3588.

3. You have the right to see and copy PHI about you.

You have the right to request to see and receive a copy of PHI contained in clinical, billing and other records used to make decisions about you. You have the right to receive your copy of PHI in its original electronic version if possible or, if not possible, in another electronic format that is mutually agreeable to you and us. Your request must be in writing. We may charge you related fees. Instead of providing you with a full copy of the PHI, we may give you a summary or explanation of the PHI about you, if you agree in advance to the form and cost of the summary or explanation.

There are certain situations in which we are not required to comply with your request. Under these circumstances, we will respond to you in writing, stating why we will not grant your request and describing any rights you may have to request a review of our denial.

You may request to see and receive a copy of PHI about you by contacting the Patient Records department at 919- 537-3515.

4. You have the right to request amendment of PHI about you.

You have the right to request that we make amendments to clinical, billing and other records used to make decisions about you. Your request must be in writing and must explain your reason(s) for the amendment.

We may deny your request if:
1) the information was not created by us (unless you prove the creator of the information is no longer available to amend the record);
2) the information is not part of the records used to make decisions about you;
3) we believe the information is correct and complete; or
4) you would not have the right to see and copy the record as described in paragraph 3 above.

We will tell you in writing the reasons for the denial and describe your rights to give us a written statement disagreeing with the denial.

If we accept your request to amend the information, we will make reasonable efforts to inform others of the amendment, including persons you name who have received PHI about you and who need the amendment.

You may request an amendment of PHI about you by contacting the HIPAA
Privacy Liaison at 919-537-3588.

5. You have the right to a listing of disclosures we have made.

If you ask our contact person in writing, you have the right to receive a written list of certain disclosures we have made of PHI about you. You may ask for disclosures made up to six (6) years before your request.

We are required to provide a listing of all disclosures except the following:

• For your treatment
• For billing and collection of payment for your treatment
• For health care operations
• Made to or requested by you, or that you authorized
• Occurring as a byproduct of permitted uses and disclosures
• Made to individuals involved in your care, for directory or notification purposes, or for other purposes described in subsection B.3 above
• Allowed by law when the use and/or disclosure relates to certain specialized government functions or relates to correctional institutions and in other law enforcement custodial situations (please see subsection B.2 above) and
• As part of a limited set of information which does not contain certain information which would identify you

The list will include the date of the disclosure, the name (and address, if available) of the person or organization receiving the information, a brief description of the information disclosed, and the purpose of the disclosure.

If, under permitted circumstances, PHI about you has been disclosed for certain types of research projects, the list may include different types of information, such as the name and a brief description of the protocol or research activity, a brief description of the type of PHI disclosed, the date or period of disclosure, and contact information for the research sponsor and the researcher to whom PHI was disclosed.

If you request a list of disclosures more than once in 12 months, we can charge you a reasonable fee. You may request a listing of disclosures by contacting the HIPAA Privacy Liaison at 919-537-3588.

6. You have the right to a breach notification.

You have the right to receive notice in the event of a breach of your unsecured PHI.

7. You have the right to a copy of this Notice.

You have the right to request a paper copy of this Notice at any time by contacting the HIPAA Liaison. We will provide a copy of this Notice no later than the date you first receive service from us (except for emergency services, and then we will provide the Notice to you as soon as possible).

D. You may file a complaint about our privacy practices.

If you think we have violated your privacy rights, or you want to complain to us about our privacy practices, you can contact the person listed below:

HIPAA Privacy Liaison
UNC Adams School of Dentistry
CB # 7450
385 S. Columbia Street
Chapel Hill, NC 27599-7450
Phone: (919) 537-3588
sod-privacy@unc.edu

HIPAA Privacy Officer
University of North Carolina at Chapel Hill
CB #1150
440 W. Franklin Street
Chapel Hill, NC 27599
Phone: (919) 962-6332
privacy@unc.edu

You may also send a written complaint to the United States Secretary of the Department of Health and Human Services. Contact information can be found at the website for the Office of Civil Rights at www.hhs.gov/ocr.

If you file a complaint, we will not take any action against you or
change our treatment of you in any way.

E. Effective Date of This Notice

This Notice of Privacy Practices is effective on May 1, 2018.

The UNC Adams School of Dentistry complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Adams School of Dentistry does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

A. Free Aids and Services

The Adams School of Dentistry:

• Provides free aids and services to persons with disabilities, such as:
  • Qualified sign language interpreters
  • Written information in other formats (large print, audio, accessible electronic formats)
• Provides free language services to persons whose primary language is not English, such as
  • Qualified interpreters
  • Information written in other languages

If you need assistance in obtaining these free services, contact:

Interpretation Services
Office of Clinical Affairs
Phone: (919) 537-3660

B. Grievances

If you believe that the UNC Adams School of Dentistry has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Director of Risk & Regulatory Affairs
Office of the Dean
Phone: (919) 537-3907

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the individual listed above is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue, SW, Room 509F, HHH Building, Washington D.C. 21201; 1-800-368-1019; 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/filing-with-ocr/index.html.

C. Attention

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Read the full policy here.

Click here to open a copy of the authorization to release patient information form.