Notice of Privacy Practices
Your Information. Your Rights. Our Responsibilities.
Polkadot Pediatric Dentistry
4190 Old Milton Pkwy #2K
Alpharetta, GA 30005
Phone: 678-389-6669
Email: info@polkadotdental.com
Effective Date: October 7, 2026
This notice describes how medical and dental information about you may be used and disclosed and how you can access this information. Please review it carefully.
Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of Polkadot Pediatric Dentistry’s responsibilities.
Get an Electronic or Paper Copy of Your Health Record
You can ask to see or receive an electronic or paper copy of your orthodontic and health records and other health information we maintain about you.
We will provide a copy or summary of your health information, generally within 30 days of your request. We may charge a reasonable, cost-based fee as permitted by law.
Ask Us to Correct Your Health Record
You can ask us to correct health information about you that you believe is incorrect or incomplete.
We may deny your request in certain circumstances. If we do, we will explain the reason to you in writing, generally within 60 days.
Request Confidential Communications
You can ask us to contact you in a specific way, such as at your home, office, or mobile phone, or to send correspondence to a different address.
We will accommodate reasonable requests.
Ask Us to Limit What We Use or Share
You can ask us not to use or share certain health information for treatment, payment, or health care operations.
We are not required to agree to every request. For example, we may deny a request if limiting the information could affect your care.
If you pay for a service or health care item completely out of pocket, you may ask us not to share information about that service with your health insurer for payment or health care operations. We will honor that request unless a law requires us to share the information.
Get a List of Certain Disclosures
You can ask us for a list, sometimes called an “accounting of disclosures,” showing certain times we shared your health information during the six years before the date of your request, including whom we shared it with and why.
The accounting does not include all disclosures. For example, disclosures made for treatment, payment, and health care operations generally are not included.
We will provide one accounting during any 12-month period at no charge. We may charge a reasonable, cost-based fee for additional requests made within the same 12-month period.
Get a Copy of This Privacy Notice
You can request a paper copy of this notice at any time, even if you previously agreed to receive it electronically.
Choose Someone to Act for You
If you have given someone medical power of attorney or another person has legal authority to act on your behalf, that person may exercise your rights and make choices regarding your health information.
We may verify that the person has this authority before taking action.
For minor patients, parents, guardians, and other legally authorized representatives may exercise rights on behalf of the patient as permitted by applicable law.
File a Complaint if You Believe Your Rights Have Been Violated
If you believe your privacy rights have been violated, you may contact:
Privacy Officer
Polkadot Pediatric Dentistry
4190 Old Milton Pkwy #2K
Alpharetta, GA 30005
Phone: 678-389-6669
Email: info@polkadotdental.com
You may also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights.
Polkadot Pediatric Dentistry will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you may tell us your preferences about what we share.
If you have a clear preference for how we share your information in the situations described below, please tell us what you want us to do. We will follow your instructions when we are able to do so and when required by law.
You generally have a choice regarding whether we:
- Share certain information with family members, friends, caregivers, or others involved in your care.
- Share information in a disaster-relief situation.
- Contact you for certain marketing purposes.
If you are unable to communicate your preference, such as during an emergency, we may share information when we believe it is in your best interest and the disclosure is permitted by law.
We may also share information when necessary to lessen a serious and imminent threat to health or safety.
Marketing and Sale of Health Information
We will obtain your written authorization before using or disclosing your protected health information for purposes that require authorization under HIPAA.
We will not sell your protected health information without your written authorization when authorization is required by law.
If you provide authorization, you may revoke it in writing at any time. Revocation will not affect actions already taken based on your previous authorization.
How We Typically Use and Share Your Health Information
Polkadot Pediatric Dentistry may use and disclose your health information in the following ways.
Treat You
We can use your health information and share it with other health care professionals who are involved in your treatment.
Example: We may share orthodontic records, X-rays, scans, photographs, treatment plans, or other relevant information with your general dentist, oral surgeon, pediatric dentist, periodontist, or another provider involved in your care.
Operate Our Practice
We can use and share your health information to operate Polkadot Pediatric Dentistry, improve the quality of care we provide, and contact you when necessary.
Example: We may review treatment records to evaluate the quality of our services, train members of our team, coordinate scheduling, or manage your orthodontic treatment.
Bill for Your Services
We may use and share your health information to bill and obtain payment from insurance companies, dental benefit plans, or other entities responsible for payment.
Example: We may provide information about your orthodontic treatment to your dental insurance company to determine benefits or obtain payment.
Contact You About Your Care
We may use your information to communicate with you regarding your orthodontic care.
This may include:
- Appointment confirmations and reminders
- Scheduling or rescheduling appointments
- Treatment instructions
- Retainer or appliance reminders
- Follow-up care
- Billing or insurance matters
- Other communications related to your treatment
Depending on the contact information you provide and your communication preferences, these communications may occur by telephone, voicemail, text message, email, mail, or other permitted methods.
Other Ways We May Use or Share Your Information
We may also use or disclose your health information when permitted or required by law.
Help With Public Health and Safety Issues
We may share health information in certain situations involving:
- Preventing disease
- Reporting adverse reactions or problems with products
- Reporting suspected abuse or neglect when required or permitted by law
- Preventing or reducing a serious threat to someone’s health or safety
Comply With the Law
We will disclose information about you when federal, state, or local law requires us to do so.
Health Oversight Activities
We may share information with health oversight agencies for activities authorized by law, such as audits, investigations, inspections, and professional licensing matters.
Workers’ Compensation
We may disclose health information as permitted by or required for workers’ compensation and similar programs.
Law Enforcement and Government Requests
We may share information in limited circumstances involving:
- Law enforcement officials
- Health oversight agencies
- Authorized government functions
- Correctional institutions or law-enforcement custody
- Other government requests permitted or required by law
Respond to Lawsuits and Legal Proceedings
We may disclose health information in response to a court or administrative order, subpoena, discovery request, or other lawful process when permitted or required by law.
Work With Medical Examiners or Funeral Directors
When applicable, we may share health information with a coroner, medical examiner, or funeral director as authorized by law.
Research
We may use or disclose health information for research when applicable legal requirements have been satisfied.
Photographs, X-Rays, Digital Scans and Orthodontic Records
As part of orthodontic treatment, Polkadot Pediatric Dentistry may create and maintain clinical photographs, X-rays, digital scans, impressions, models, treatment plans, progress records, and other information relating to your care.
These materials are considered part of your health information when they identify you or can reasonably be linked to you.
We may use these materials as permitted by law for treatment, payment, health care operations, and other purposes described in this notice.
Uses of identifiable patient photographs, videos, testimonials, or treatment information for purposes requiring patient authorization will be made only with appropriate authorization.
Electronic Communications and Patient Information
Polkadot Pediatric Dentistry may use electronic systems to manage patient information and communicate regarding treatment, appointments, billing, and other practice matters.
We take reasonable administrative, technical, and physical safeguards to protect electronic health information.
Please be aware that ordinary email and text messaging can carry privacy risks. You may contact our office if you would like to request a different method of communication.
Substance Use Disorder Records
If Polkadot Pediatric Dentistry receives or maintains substance use disorder patient records that are specifically protected by 42 CFR Part 2, additional federal protections may apply.
To the extent that we maintain records subject to 42 CFR Part 2, those records will not be used or disclosed in civil, criminal, administrative, or legislative proceedings against you unless permitted by applicable law, including where appropriate through your written consent or a qualifying court order and subpoena.
Our Responsibilities
Polkadot Pediatric Dentistry is required by law to maintain the privacy and security of your protected health information.
We are also required to:
- Follow the privacy practices described in this notice.
- Provide you with a copy of this notice upon request.
- Notify you promptly if a breach occurs that may have compromised the privacy or security of your protected health information, as required by law.
- Limit uses and disclosures of protected health information as required by applicable law.
- Honor the privacy rights described in this notice.
We will not use or share your information for purposes other than those described in this notice unless you provide written authorization or another use or disclosure is permitted or required by law.
If you authorize us to use or disclose your information, you may revoke that authorization in writing at any time. Your revocation will not affect information already used or disclosed in reliance on your authorization.
Changes to This Notice
We may change the terms of this Notice of Privacy Practices.
Changes may apply to all health information we maintain about you, including information created or received before the change.
If we make a material change, the updated notice will be available upon request, at our office, and on our website.
Questions or Complaints
If you have questions about this notice, would like additional information about our privacy practices, or wish to make a privacy-related request or complaint, please contact:
Privacy Officer
Polkadot Pediatric Dentistry
4190 Old Milton Pkwy #2K
Alpharetta, GA 30005
Phone: 678-389-6669
Email: info@polkadotdental.com
You may also submit a complaint to the:
U.S. Department of Health and Human Services
Office for Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201