Privacy Practices and Patient Rights

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Patient Bill of Rights

As a patient at the Tufts University School of Dental Medicine, you have the right to:

  • A written copy of your rights on admittance
  • A written copy of our rules and regulations
  • Confidentiality of all records
  • Inspection of your record and copies on request
  • The name of the faculty member in charge of your care
  • Prompt response to requests
  • Access to and copies of financial records including third party transactions
  • Access to care regardless of physical or mental disability, including individuals with HIV infection or who are perceived to have or be at risk of having HIV infection

As a teaching institution where students are the sole provider source, Tufts University School of Dental Medicine reserves the right to decline to be a provider of treatment when:

  • The patient does not keep scheduled appointments or cancels or reschedules appointments with less than 24 hours’ notice
  • The patient or responsible third parties are unable to finance a reasonable plan for oral health care
  • The patient exhibits disruptive behavior

Notice Of Privacy Practices

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.

Tufts University School of Dental Medicine (“TUSDM”) is required by law to maintain the privacy of your protected health information and to provide you with a notice of our legal duties and privacy practices with respect to protected health information. This Notice is required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).This Notice of Privacy Practices (Notice) describes how we may use and disclose your protected health information, our obligations regarding the use and disclosure of your protected health information, and your rights with respect to the use and disclosure of your protected health information.


TUSDM is legally required to follow the privacy practices that are described in this Notice. We are legally required to protect the privacy of information that identifies you or could be used to identify you, and relates to your past, present or future physical or mental health condition(s) or the provision of past, present, or future healthcare services (including payment for those services).  This information is called “protected health information” or PHI for short.

TUSDM may record, transmit, or maintain personal information about you, your medical history or treatment as part of providing you with healthcare services.

We reserve the right to change our privacy policies and the terms of this Notice at any time.  Before any important policy change goes into effect, we will change this Notice. We will post a copy of this Notice in the dental school clinics for public viewing.  You may also request a copy of this Notice at any time by contacting TUSDM’s Compliance Department at

Your Rights Regarding Your PHI

Although your medical information is the property of TUSDM, you have certain rights regarding your PHI, including the right to:

  • Inspect and Copy.  With certain limited exceptions, you have the right to inspect or receive a copy of your medical information or both.  We may charge a fee for these services.  We may deny your request in certain limited circumstances.  If you are denied access to your medical information, you may request that the denial be reviewed.  Another licensed healthcare professional chosen by TUSDM will review your request and our denial.
  • Request an Amendment.  If you feel that the PHI we have about you is incomplete or incorrect, you may ask us to amend such information.  We may deny your request if you ask us to amend information that (a) was not created by TUSDM; (b) is not part of the medical information kept by or for TUSDM; (c) is not medical information you are permitted to inspect or copy; or (d) is accurate and complete in the record.
  • Request an Accounting of Disclosures.  You may request a list of the disclosures we have made of PHI that were for purposes other than treatment, payment, healthcare operations and certain other purposes, or disclosures made at your request or with your written authorization within the last six (6) years.  You may be charged a fee in connection with this request. To request an accounting, you must submit your request, in writing, to the address listed below.
  • Restrict or Limit Use or Disclosure.  You have the right to request a restriction or limitation on the use or disclosure of your PHI, including the disclosure of information to someone who is involved in your care or the payment for your care, such as a family member or friend (or other individual).  Your written request must state: (1) what information you want to limit; (2) whether you want to limit TUSDM’s use, disclosure or both; and (3) to whom the limits apply, for example, disclosures to your spouse.  We are not required to agree to your request, unless it relates to an item or service you paid for in full and out of pocket.

Request Non-disclosure to Health Plans for Items or Services that are Self-Paid: If you pay out-of-pocket in full for health care items or services and, prior to the service, you request to restrict TUSDM from disclosing the health care item(s) or service(s) to your Health Plan, TUSDM must honor that request. We will comply with such requests unless the information is needed to provide you emergency treatment, or except as required by law.

  • Request Communication of your Information by Alternative Means.  Generally, we will use the address, telephone number and, in some cases, the email address you give us to contact you.  You may request that we communicate with you about medical matters in a certain way or at a certain location.  For example, you can ask that we contact you only at work.  We will accommodate all reasonable requests.  Your written request must specify how or where you wish to be contacted.
  • Notification of a Breach.  Consistent with federal and state laws, we will notify you in the event your unsecured PHI is used or disclosed by an unauthorized individual, or is lost or stolen.

Use and Disclosure of Your PHI by TUSDM

To carry out its responsibilities as a healthcare provider, Tufts may use or disclose your PHI without your authorization for the following reasons:

  • Treatment.  Tufts may disclose PHI to dentists, physicians, nurses, technicians, hospitals, dental and medical students or other personnel who treat you at TUSDM or other locations.
  • Payment.  We may use or disclose PHI to bill or collect payment for the treatment and services you receive at TUSDM or other healthcare facilities.  We may also use or disclose PHI to establish your eligibility for insurance benefits.
  • Healthcare Operations.  We may use or disclose PHI to carry out “healthcare operations” at TUSDM, including activities related to improving quality of care, staff training, dental and medical education, and business management.
  • Appointment Reminders, Information about Healthcare Related Benefits and Treatment Alternatives.  We may use or disclose PHI to contact you as a reminder that you have an appointment for a treatment or medical care at TUSDM or to inform you of treatment alternatives or other healthcare services or benefits that we offer.
  • Fundraising Activities.  We may contact you regarding our fundraising activities.  If you do not wish to be contacted for our fundraising efforts, please notify us in writing at the address or email address provided below.  You may opt out of receiving communications regarding our fundraising activities at any time.
  • Research.  All research studies conducted at TUSDM must be approved by an institutional review board that has reviewed the research proposal and established protocols to protect patient safety, welfare and confidentiality.  Subject to the confidentiality provisions of state and federal law, we may use or disclose your PHI for qualified research purposes. Researchers may contact TUSDM patients about participating in research studies.  Enrollment in those studies can occur only after you have been informed about the study, had an opportunity to ask questions and indicated your willingness to participate by signing a consent form.
  • As Required By Law.  We will use or disclose PHI when required to do so by federal, state or local law, including in response to a court or administrative order, subpoena, discovery request, warrant, summons or other lawful process.  TUSDM may also disclose PHI to law enforcement personnel or similar persons to avoid a serious threat to the health or safety of a person or the public.

TUSDM also may use or disclose your PHI without your authorization under the following circumstances:

  • emergency situations when your authorization cannot be reasonably obtained, including for disaster relief purposes;
  • to business associates (outside vendors or consultants that perform services on behalf of TUDSM and are contractually required to appropriately safeguard your information);
  • with your agreement, to a family member, relative, close personal friend, or any other person you identify;
  • to facilitate organ or tissue donation if you are an organ donor;
  • in connection with workers’ compensation claims;
  • to report abuse, neglect, or domestic violence as required by state of federal law;
  • for public health and health oversight activities, such as preventing or controlling disease or investigations; or
  • to coroners, medical examiners, or funeral directors as necessary to carry out their duties.

Certain actions — such as most uses or disclosures of psychotherapy notes, the use or disclosure of PHI for marketing purposes, or the sale of PHI — may be made only with your written permission (authorization).  In addition, Massachusetts provides special privacy protections for particularly sensitive conditions or illnesses such as HIV/AIDS, mental health, and substance abuse.  TUSDM will disclose such information only in a manner that is consistent with these laws.

Uses or disclosures of PHI not addressed in this Notice will be made only with your written permission.

You may revoke your permission to use or disclose PHI at any time by writing to the address or email address below.  Once you revoke your permission, we will stop using or disclosing such information for the reasons covered by your written authorization.  However, we cannot take back any disclosures made with your permission.  We will retain our records of the care provided to you as required by law.

All requests must be submitted in writing to the address below. Your request should be specific and must be signed and dated by you or an authorized representative.


If you believe your privacy rights have been violated, you may file a complaint by writing to the address below or by calling the Tufts University confidential reporting hotline at 1-866-384-4277.  You may also file a complaint in writing with the Secretary of the U.S. Department of Health and Human Services in Washington, D.C. or through the regional office at J.F.K. Federal Building – Room 1874, Boston, MA 02203.  The complaint must be filed within 180 days of the alleged violation.  There will be no retaliation for filing a complaint.

Contact Information

If you have questions, would like to submit a written request, or need further assistance regarding this policy, please contact TUSDM’s Compliance Office at:

Compliance Department
Tufts University School of Dental Medicine
One Kneeland Street
Boston, Massachusetts 02111

Effective Date

This Notice of Privacy Practices is effective July 1, 2013.

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