Birch Street Dentistry: Notice of Privacy Practices
Effective Date of This Notice: February 04, 2026
Address: 1120 Birch Street, Fairmont, MN 56031-4418 Website: https://drfordice.com/ Privacy Officer: Sarah Becker
Your Information. Your Rights. Our Responsibilities. This notice describes how your dental/health information may be used and disclosed by Birch Street Dentistry and how you can get access to this information. Please review it carefully.
Your Rights
You have certain rights pertaining to your health information. Your rights and some of our responsibilities are:
1. Obtain an electronic or paper copy of your dental record
You can ask to see or request an electronic or paper copy of your dental record and other health information we have about you. Ask us how to do this.
Upon written request, we will provide a copy or summary of your dental/health information within a reasonable time.
If you ask to see or receive a copy of your record for purposes of reviewing current dental care, we may not charge you a fee.
If you request copies of your patient records of past dental care, or for certain appeals, we may charge you specified fees.
2. Request your dental record be amended or corrected
You can ask us to correct dental/health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we’ll tell you why in writing within 60 days.
3. Request us to contact you confidentially
You can ask us to contact you in a specific way (for example, by home or office phone) or by sending mail to a different address. We will say “yes” to all reasonable requests.
4. Request us to limit what we use or share
You can ask us not to use or share certain health information for treatment, payment, or our operations (TPO). We are not required to agree to your request, and we may say “no” if it would affect your care. Such requests should be made in writing.
Out-of-pocket payments: If you pay for a service or dental/health care item out-of-pocket in full, you can ask us not to share that information, for the purpose of payment or our operations, with your dental/health insurer. We will say “yes” unless a law requires us to share that information.
5. Get a list of those with whom we’ve shared information
You can ask for a list (an accounting) of the times we’ve shared your dental/health information during the previous six years from the date you ask, including who we shared it with and why. Such requests should be made in writing.
We will include all the disclosures except for those about treatment, payment, and dental care operations, and certain other disclosures such as any you asked us to make.
We will provide one list/accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
6. Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time and we will do so promptly, even if you agreed to receive it electronically.
7. File a complaint if you feel your rights are violated
You can complain if you feel we have violated your rights by contacting our Privacy Officer using the contact information at the top of this page. We will not retaliate against you for filing a complaint.
You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by:
Mail: 200 Independence Avenue, S.W., Washington, DC 20201
Phone: 1-877-696-6775
Online: www.hhs.gov/ocr/privacy/hipaa/complaints/
Your Choices
For certain health information, you can tell us your choices about what we share
If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your written instructions.
You have both the right and choice to tell us NOT to:
Share information with your family, close friends, or others involved in your care, such as your personal representative.
Share information in a disaster relief situation.
Note: If you are not able to tell us your preference, for example if you were unconscious, we may share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
Cases in which we will never share your information unless you give us written permission
We will not share your information for marketing purposes, sale of your information, or most sharing of psychotherapy notes without your written permission.
Fundraising
We may contact you for fundraising efforts, but you can tell us not to contact you again.
Your Authorization
If you provide an authorization in writing to permit other uses or disclosures of your dental/health information that are not described in the “Our Uses and Disclosures” section, you may revoke such authorization in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.
Our Uses and Disclosures
How we typically use or share your dental/health information
We need your consent before we disclose protected health information except in specific scenarios or medical emergencies. We typically share your dental/health information in the following ways:
Treating You: We can share your health information with a provider in our Birch Street Dentistry network. We can use your dental/health information and share it with other professionals (such as other dentists, physicians, pharmacists, or lab personnel) who are treating you. We may ask for your consent prior to disclosures for treatment.
Example: A doctor treating you for an injury asks another doctor about your overall health condition.
Payment/Billing: We can use and share your dental/health information to bill and get payment from health plans or other entities. We may ask for your consent prior to disclosures for payment.
Example: We give information about you to your health insurance plan so it will pay for your services.
Organizational Operations: We can use and share your dental/health information in connection with our healthcare operations to run our practice, improve your care, and contact you when necessary. We may ask for your consent prior to disclosures for organizational operations.
Examples: Business planning, management and administrative services, quality assessment, and evaluating our dental professionals.
Other uses and disclosures for sharing your dental/health information
We are allowed or required to share your information in other ways that contribute to the public good, such as public health and research. We must meet many conditions in the law before sharing your information for these purposes.
Public health and safety: We can share dental/health information about you for situations such as preventing disease, helping with product recalls, reporting adverse reactions to medications, reporting suspected abuse/neglect, disaster relief efforts, and preventing serious threats to health or safety.
Research: We can use or share your information for health research if you don’t object.
To comply with the law: We will share information about you if state or federal laws require it.
Respond to organ and tissue donation requests: We can share health information about you with organ procurement organizations.
Work with a medical examiner or coroner: We can share dental/health information with a coroner and medical examiner when an individual dies.
Workers’ compensation, law enforcement, and other government requests: We can use or share dental/health information about you for workers’ compensation claims, for law enforcement purposes, or with health oversight agencies. This includes special government functions such as military and national security services.
Respond to lawsuits and legal actions: We can share dental/health information about you in response to a court or administrative order, or in response to a subpoena. We will consult legal counsel upon receipt of such documents.
Other State Law Considerations
We are required to describe any state or other laws that require greater limits on disclosure. For example, we will not share any substance abuse, HIV/AIDS, or psychotherapy treatment records without your written permission.
Electronic Communication and Appointment Reminders
We may use or disclose your health information when contacting you to remind you of a dental appointment or other purposes relating to your treatment at Birch Street Dentistry. We may contact you by using a postcard, letter, phone call, voice message, text message, or email communication.
Substance Abuse Records
Our organization does not provide substance use disorder treatment. However, if we receive or maintain information related to substance use disorder treatment, that information may be subject to additional protections under federal and state law. We will use and disclose such information only as permitted or required by law.
Our Responsibilities
Maintain privacy & security: We are required by law to maintain the privacy & security of your protected health information.
Inform you if a breach occurs: We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
Follow notice practices: We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not share your information other than described here unless you tell us we can in writing.
Changes to the Terms of This Notice We can change the terms of this notice, and such changes will apply to all your information we have, including health information we created or received before any notice changes. Revised notices will be available upon request, in our office, and on our website.
For more information, please visit: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html
Privacy Officer Contact Information
Sarah Becker Birch Street Dentistry 1120 Birch Street, Fairmont, MN 56031-4418 Phone: 15072384276 Email: dr.fordice@gmail.com