Prairie Oral Surgery is committed to preserving the privacy and confidentiality of your health information. This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. Please review it carefully.


This form, Notice of Privacy Practices, presents the information that federal law requires us to give our patients regarding our privacy practices.

Our Legal Duty

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect May 15, 2015, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may access or obtain a copy according to the following options: 1) download a full pdf version from our website (available below), 2) contact the office and request a copy be sent to you by main or email, 3) request a copy at the time of your next appointment. Please contact us if there’s additional concerns or questions.

Uses and Disclosures of Protected Health Information

Your PHI may be used or disclosed for the purpose of providing healthcare services to you.

Treatment: We will use or disclose your PHI to provide, coordinate or manage your dental care and any related service.

Payment: We will use or disclose your PHI to obtain payment for the dental care services provided by this Practice. We may use or disclose your PHI to verify eligibility or coverage for benefit determination or so a bill can be sent which includes services provided.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Business Associates: We may share your PHI with third party business associates such as answering services, billing services, consultants, etc. We obtain a written agreement between our Practice and the business associate to assure the privacy and protection of your PHI.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. If you revoke this authorization, we will no longer use or disclose your PHI; however, we are unable to retrieve previous disclosures made under the prior authorization.

Students: We may share PHI with students working in our Practice to fulfill their educational requirements. If you do not wish a student to observe or participate in your care, please notify your provider.

Family and Close Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

As Required by Law: We may use or disclose your health information when we are required to do so by law. Please see examples as provided in the full Notice of Privacy Practices.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information if necessary to avert a serious threat to your health or safety or the health or safety of others.

Disaster Relief: We may disclose your PHI to an authorized public or private entity to assist in disaster relief efforts.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages or letters).

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Patient Rights

Access: You have the right to look at or get copies of your protected health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we may assess a $20.00 charge for staff labor and copying charges, in accordance with North Dakota law. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Our Practice does not transmit unsecure PHI via email.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. You must submit your request in writing to the Privacy Officer.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). If you paid out-of-pocket for a service, you have the right to request that information not be disclosed to a health plan for purposes of payment or health care operations.

Confidential Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request. Our staff will not ask personal questions regarding your request.

Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.

Breach Notification: You have the right to be notified following a breach of unsecured PHI that affects you.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

Questions & Complaints

We support your right to the privacy of your protected health information. Please, contact us if you want more information about our privacy practices, or if you have questions or concerns. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice.

You also may submit a written complaint to the Secretary of Health and Human Services at: U.S. Department of Health and Human Services, Office of Civil Right, 200 Independence Avenue, SW, Washington DC 20201. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Dept. of Health & Human Services.

Contact Officer

Office Administrator, Prairie Oral Surgery
2585 23rd Ave S, Suite #A
Fargo, ND 58103

Email: Click Here to E-mail Privacy Officer