HIPAA Notice of Privacy Practices

Kriger Orthodontics -Dr. Maryann Kriger, DDS

Bonita Springs Office: 27970 Crown Lake Blvd, #2, Bonita Springs FL 34135, (239) 947-1235
Marco Island Office: 987 North Collier Blvd, Marco Island, FL 34145, (239) 394-1236
Fort Myers Office: 7780 Cambridge Manor Place, Fort Myers, FL 33907, (239) 689-5515


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 (TPO) and for other purposes that are permitted or required by law. It
also describes your rights to access and control your protected health information. “Protected health information” is
information about you, including demographic information, that may identify you and that relates to your past, present or
future physical or mental health or condition and related health care services. Any information or inquiries acquired via
email, phone, fax or office visits is considered confidential information. Dr. Maryann Kriger will not disclose your
individual identity or other personal information without your prior consent, except as required by law.

1. Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your doctor, our office staff and others outside of our
office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your
health care bills, to support the operation of the doctor’s practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health
care and any related services. This includes the coordination or management of your health care with a third party. For
example, your protected health information may be provided to a doctor to whom you have been referred to ensure that
the doctor has the necessary information to diagnose or treat you.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For
example, obtaining approval for a surgery may require that your relevant protected health information be disclosed to the
insurance health plan or hospital to obtain approval for payment of the surgery.

Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the
business activities of your doctor’s practice. These activities include, but are not limited to, quality assessment activities,
employee review and training activities, licensing, and conducting or arranging for other business activities. For example
your xrays and photographs may be used for in office training as well as posting on our website and social media,
however, your full name will never be disclosed.

We may use a sign-in sheet at the registration desk where you will be asked to sign your name. We may also call you by
name in the waiting room when your doctor is ready to see you. We may use or disclose your protected health
information, as necessary, to contact you via email and phone to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your authorization. These
situations include: as required by federal, state, or local law; public health issues as required by law; to avert a serious
threat to health or safety; emergency situations; Food and Drug Administration requirements; legal proceedings; law
enforcement; if you are an organ donor, for organ or tissue donation; Workers’ Compensation; for coroners, medical
examiners, and funeral directors; and information about inmates can be released to law enforcement officials or
correctional institutions with custody.

Other Permitted and Required Uses and Disclosures Will Be Made Only With Your Consent, Authorization or
Opportunity to Object unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that your doctor or the doctor’s practice
has taken an action in reliance on the use or disclosure indicated in the authorization.

Surveys, Contests & Social Media
From time-to-time we may request information via surveys or contests. Participation in these surveys or contests or
Social medial postings is completely voluntary and you may choose whether or not to participate and therefore disclose
this information. Information requested may include contact information (such as name and shipping address, email), and
demographic information (such as zip code, age level) and treatment before and after. Contact information will be used to
notify the winners and award prizes. Survey information will be used for purposes of monitoring or improving the use and
satisfaction of our services.

Unless you ask us not to, we may contact you via email or SMS in the future to tell you about specials, new products or
services, or changes to this privacy policy.

E-Mail Privacy Warning
E-mail is not a secure communication’s medium. Personal information sent via the Internet can be intercepted. You may,
therefore, wish to reconsider the advisability of sending messages that contain highly sensitive or personal information to
our email or website.

2. Your Rights
The following is a statement of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information. Under federal law, however, you may not
inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in,
a civil, criminal, or administrative action or proceeding; and protected health information that is subject to law that
prohibits access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or
disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations.
You may also request that any part of your protected health information not be disclosed to family members or friends
who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your
request must state the specific restriction requested and to whom you want the restriction to apply.

Your doctor is not required to agree to a restriction that you may request. If the doctor believes it is in your best interest to
permit use and disclosure of your protected health information, your protected health information will not be restricted.
You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative
location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept
this notice alternatively i.e., electronically.

You may have the right to have your doctor amend your protected health information. If we deny your request for
amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your
statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health
information. We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then
have the right to object or withdraw as provided in this notice.

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been
violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate
against you for filing a complaint.

This notice was published and became effective on April 14, 2003. We are required by law to maintain the privacy of, and
provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information.

If you have any objections to this form, please call us at 239-947-1235 or email us at BonitaOrtho@live.com