We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to provide you with this Notice about our privacy practices, our legal duties, and your rights concerning your protected health information. We must follow the privacy practices that are described in this Notice while it is in effect and notify you if we cannot accommodate a requested restriction. 

We reserve the right to change our privacy practices and the new terms of our Notice will be effective for all health information 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 will make a new Notice available on request.

You will be asked to sign a consent form authorizing our use and disclosure of protected health care information and acknowledging that you have received this Notice. You have the right to review this Notice prior to signing the consent. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this notice.


Federal law protects your health information. Protected Health Information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnosis and treatments. It also includes billing documents for those services. We use and disclose health information about you for treatment, payment and healthcare operations. For Example:

Treatment: We may disclose your health information to a physician or other healthcare provider providing treatment to you. (Physical therapists/Consultants/Nurses); in order to set up an appointment, prescribe medications (by fax or otherwise), and/or obtaining copies of your records from prior treating practitioners.

Payment: We may use and disclose your health information to obtain payment for services we provide to you. (Insurance company/Third party administrator); such as: asking about your dental and medical coverage, preparing and sending bills and/or collecting fees due including use of a collection agency or attorney.

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. We may also use and disclose information during the general administrative functioning of our office.

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. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in the notice. No authorization from you is required for our normal operations. We will ask you for special written authorization for disclosures related to HIV/AIDS status, practice marketing and sales, or sale of any information.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient’s 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 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 your 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 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.

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

Required by Law: We may use or disclose your health information when we are required to do so by law including but not limited to requirements of government agencies such as the FDA, NYS Health Department, Workman’s Compensation Boards, Law Enforcement or Correctional agencies having legal custody or courts of competent jurisdiction. Examples include but are not limited to instances that federal/state law mandate reporting, public health issues, Medicare/Medicaid audits, or disclosure to business associates who are required by law to protect the privacy of your protected healthcare information.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders such as voice mail messages, postcards or letters, unless you direct us otherwise in writing..

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 to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

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 officials having lawful custody of protected health information of inmates or patients under certain circumstances.


Access: The health and billing records we maintain are the physical property of the practice. The information in it, however, belongs to you. You have the right to look at or get copies of your 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 healthcare 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 will charge you $.75 for each page and $25.00 for each x-ray copied. If you request health information in an alternative format, a reasonable cost based fee will be charged. If you prefer, we will prepare a summary or an explanation of your healthcare information for a fee. We may, at our discretion, waive the fee for copies.)

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 your treatment, payment healthcare operations and certain other activities, for the last six (6) years
but not before April 14, 2003. If you request this accounting more than once in a twelve (12) month period, we may charge you a reasonable, cost based fee for responding to theses additional requests. An accounting will not include internal uses of information for treatment, payment, or operations, disclosure mad to you or at your request, or disclosures made to family members or friends in the course of treatment.

Restriction: You have the right to request that we place additional restrictions on the 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 emergencies). We must honor your request to not disclose information to healthcare insures if you have personally paid for your care. All requests for restrictions on disclosure of your records must be in writing.

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or at an alternative location. (You must make this request in writing and your request must specify the alternative means or location and provide satisfactory explanation how payments will be handled using the alternative location or means of communication).

Amendment: You have the right to request that we amend your health information. We may deny your request under certain circumstances. Any request to amend health information must be in writing and must set forth, with specificity, the information to be amended. If your amendment is denied, you have the right to file a Statement of Disagreement. If you do so, the request for amendment and the denial will be attached to all future disclosures of your protected health information. We will send corrected information to any parties you specify. By law, we have 30 days to decide if we will deny your requests.

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.


If you want more information about our privacy practices or have questions or concerns, please contact us.

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 disclosure of your health information or to have us communicate with you at alternative locations or by alternative means, you may complain to us using the contact information listed at the end of this Notice. You may also submit a written complaint to the United States Department of Health and Human Services. We will provide you with the address to file your complaint with the USDHHS upon request.

We support your right to the privacy of your health information. We cannot, and will not, require you to waive the right to file a complaint with the USDHHS as a condition of receiving treatment from this practice. We will not retaliate in any way if you choose to file a complaint with us or with the USDHHS.

Contact Officer: Harry G. Sacks, D.D.S., J.D. Tel: Oral and Maxillofacial Surgery of Nassau & Queens, LLP Phone Number (516) 437-2666
  2035 Lakeville Rd. Fax: (516) 358-6954
  Suite 204 Email: [email protected]
  New Hyde Park, New York 11040