201 S. Emerson Ave Suite 130, Greenwood, IN 46143
New Patients: (317) 886-4512 | Current Patients: (317) 888-4044
Effective Date: January 1, 2024
Last Updated: 2025
Beautiful Smiles and Dr. Ben Stevens are committed to protecting the privacy of your health information. We are required by law to maintain the privacy of your Protected Health Information (PHI), to provide you with this Notice of our legal duties and privacy practices with respect to PHI, and to abide by the terms of this Notice currently in effect.
"Protected Health Information" (PHI) means 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, the provision of health care services to you, or the past, present, or future payment for the provision of health care to you.
The following describes the ways we may use and disclose your PHI. Not every use or disclosure will be listed. We will make reasonable efforts to use, disclose, and request only the minimum amount of PHI necessary to accomplish the intended purpose.
2.1 Treatment
We may use and disclose your PHI to provide, coordinate, or manage your dental health care and any related services. This includes sharing your information with other health care providers involved in your treatment. For example, we may send X-rays and treatment records to a specialist to whom we refer you, or share records with your primary care physician when medically relevant.
2.2 Payment
We may use and disclose your PHI to obtain payment for services we provide to you. This may include submitting claims to your dental insurance company, verifying insurance coverage, and collection activities. For example, we may send a claim to your insurance carrier that includes information about the dental services we provided.
2.3 Health Care Operations
We may use and disclose your PHI in connection with our health care operations. Health care operations include quality assessment and improvement activities, reviewing the qualifications of our dental professionals, conducting training, and other business management functions.
2.4 Appointment Reminders
We may use and disclose your PHI to contact you as a reminder that you have an appointment for treatment or follow-up care. We may contact you by phone, text message, email, or postcard. If you prefer a specific contact method, please let our front desk team know and we will accommodate your preference.
2.5 Treatment Alternatives and Health-Related Benefits
We may use and disclose your PHI to tell you about or recommend possible treatment options or alternatives, and health-related benefits or services that may be of interest to you.
2.6 As Required by Law
We will disclose your PHI when required to do so by federal, state, or local law, including reporting requirements mandated by public health authorities, law enforcement, or oversight agencies.
2.7 Public Health Activities
We may disclose your PHI for public health activities, including reporting communicable diseases, reporting child abuse or neglect, reporting reactions to medications or problems with products, and notifying people of product recalls.
2.8 Abuse, Neglect, or Domestic Violence
We may disclose PHI to a government authority, such as a social service or protective services agency, if we reasonably believe you are a victim of abuse, neglect, or domestic violence.
2.9 Health Oversight Activities
We may disclose PHI to a health oversight agency for activities authorized by law, including audits, investigations, inspections, and licensure. This oversight is necessary for the government to monitor the health care system, government benefit programs, and compliance with civil rights laws.
2.10 Judicial and Administrative Proceedings
We may disclose your PHI in response to a court or administrative order, subpoena, discovery request, or other lawful process.
2.11 Law Enforcement
Under certain circumstances, we may disclose your PHI to law enforcement officials, such as in response to a warrant, court order, or similar process, or as permitted by law.
2.12 Organ and Tissue Donation
If you are an organ donor, we may disclose PHI to organizations that facilitate organ, eye, or tissue procurement, banking, or transplantation.
2.13 Military and Veterans
If you are a member of the armed forces, we may release your PHI as required by military command authorities.
2.14 National Security
We may disclose your PHI to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
2.15 Inmates
If you are an inmate, we may disclose your PHI to the correctional institution or law enforcement official as necessary for your health and safety and the health and safety of others.
2.16 Deceased Individuals
We may disclose PHI about a deceased individual to a coroner, medical examiner, or funeral director as authorized or required by law.
The following uses and disclosures of your PHI will only be made with your written authorization, unless an exception applies:
Most uses and disclosures of psychotherapy notes
Uses and disclosures of PHI for marketing purposes
Disclosures that constitute a sale of PHI
Any other uses or disclosures not described in this Notice
You may revoke any authorization you have given us at any time, in writing, unless we have already acted in reliance upon it. To revoke an authorization, please submit your written request to our office.
ou have the following rights with respect to the PHI we maintain about you. To exercise any of these rights, please submit a written request to our Privacy Officer at the address listed at the end of this Notice.
4.1 Right to Inspect and Copy
You have the right to inspect and obtain a copy of the PHI that we use to make decisions about your care, including dental and billing records. We may charge a reasonable, cost-based fee for copies. We must provide you with access within 30 days of your written request (or 60 days if the information is stored offsite).
We may deny your request to inspect or copy your PHI in limited circumstances. If we deny your request, we will explain the basis for the denial and whether you have the right to request a review of the denial.
4.2 Right to Request an Amendment
If you believe that PHI we have about you is incorrect or incomplete, you have the right to request an amendment. We may deny your request if the information was not created by us, is not part of the information you would be permitted to inspect or copy, is not part of our records, or is accurate and complete. If we deny your request, you may submit a written statement of disagreement, which will be included in your record.
4.3 Right to an Accounting of Disclosures
You have the right to request an accounting of certain disclosures of your PHI made by us. This right does not apply to disclosures made for treatment, payment, or health care operations; disclosures you authorized; disclosures made to you; disclosures incidental to permitted uses; and certain other disclosures. The accounting will cover disclosures made up to six years prior to the date of your request.
4.4 Right to Request Restrictions
You have the right to request restrictions on the way we use or disclose your PHI for treatment, payment, or health care operations. We are not required to agree to your requested restriction, except in one circumstance: we must agree to your request to restrict disclosure of PHI to a health plan for payment or health care operations purposes if the PHI pertains solely to a health care item or service for which you have paid us out-of-pocket in full.
4.5 Right to Request Confidential Communications
You have the right to request that we communicate with you about your dental care in a specific way or at a specific location. For example, you may ask that we contact you by email only or at a specific phone number. We will accommodate reasonable requests. Please notify our front desk team of your preferred contact method.
4.6 Right to a Copy of This Notice
You have the right to a paper copy of this Notice at any time. You may also obtain a copy from our website or by contacting our office directly.
4.7 Right to Be Notified of a Breach
You have the right to be notified if there is a breach of your unsecured PHI. We will notify you of any breach in accordance with applicable federal and state law, without unreasonable delay and in no case later than 60 calendar days following discovery of the breach.
We are required by law to:
Maintain the privacy and security of your PHI
Provide you with this Notice of our legal duties and privacy practices
Notify you if a breach of your PHI occurs that may have compromised the privacy or security of your information
Follow the terms of the Notice currently in effect
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided the changes are permitted by applicable law and the changed policy applies to all PHI we maintain. When we make a material change, we will post the new Notice in our office and on our website.
This section applies to visitors of the Beautiful Smiles website and describes how we collect, use, and protect information gathered through our website.
6.1 Information We Collect Online
When you visit our website, we may automatically collect certain non-personally identifiable information, including:
Your IP address and browser type
Pages viewed and time spent on the website
Referring website addresses
General geographic location (city/state level)
When you voluntarily submit information through our website contact forms, appointment request forms, or other online forms, we collect the information you provide, which may include your name, email address, phone number, and the nature of your inquiry.
6.2 How We Use Website Information
Information collected through our website is used to:
Respond to your inquiries and appointment requests
Improve our website content and user experience
Understand how visitors use our website
Communicate with you about our dental services
We do not sell, trade, or rent your personal information to third parties. We do not use website-submitted contact information to send unsolicited marketing communications.
6.3 Cookies and Tracking Technologies
Our website may use cookies — small data files stored on your device — to improve your browsing experience and gather aggregate website usage data. Cookies do not contain PHI. You may configure your browser to refuse cookies or to notify you when cookies are being sent, though some features of our website may not function properly without cookies.
We may also use third-party analytics tools (such as Google Analytics) to understand website traffic patterns. These tools collect anonymous, aggregated information and are governed by their own privacy policies.
6.4 Online Appointment Requests
Information submitted through our online appointment request forms is transmitted securely and is used solely for the purpose of scheduling your appointment. Online appointment requests do not constitute PHI until you become a patient of record. Once you become a patient, all information in your dental record is protected as described in Sections 1 through 5 of this policy.
6.5 Third-Party Links
Our website may contain links to third-party websites. We are not responsible for the privacy practices of those websites. We encourage you to review the privacy policies of any third-party sites you visit.
6.6 Children's Privacy Online
Our website is not directed to children under the age of 13, and we do not knowingly collect personal information from children under 13 online. If you believe a child under 13 has submitted personal information through our website, please contact us immediately so we can remove the information.
6.7 Security of Online Information
We implement reasonable administrative, technical, and physical safeguards to protect information submitted through our website. However, no method of transmission over the internet is 100% secure, and we cannot guarantee absolute security of information transmitted to us online.
For patients who are minors (under 18 years of age), we will generally share PHI with a parent or legal guardian who is the minor's personal representative under applicable law. There are limited exceptions, including situations where the minor has the legal right to consent to treatment without parental involvement, as permitted by Indiana law.
If you are the parent or legal guardian of a minor patient and have questions about accessing your child's dental records, please contact our office.
If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint.
To file a complaint with Beautiful Smiles:
Submit your complaint in writing to our Privacy Officer at the address below. We will acknowledge receipt of your complaint and investigate the matter promptly.
To file a complaint with the federal government:
Office for Civil Rights, U.S. Department of Health and Human Services
200 Independence Avenue, S.W., Washington, D.C. 20201
Phone: 1-877-696-6775 | Website: www.hhs.gov/ocr/privacy/hipaa/complaints/
For questions about this Notice, to exercise any of your privacy rights, or to file a complaint, please contact:
Beautiful Smiles — Privacy Officer
Dr. Ben Stevens, DDS
📍 201 S. Emerson Ave Suite 130, Greenwood, IN 46143
📞 New Patients: (317) 886-4512
📞 Current Patients: (317) 888-4044
This Notice is effective as of January 1, 2024. We reserve the right to change the terms of this Notice at any time. Any material changes will be posted in our office and on our website. The effective date at the top of this Notice will be updated accordingly.
The most current version of this Notice is always available at our front desk and on our website. You may request a printed copy at any time.
By signing below, I acknowledge that I have received and reviewed a copy of Beautiful Smiles' Notice of Privacy Practices. I understand that this Notice describes how my health information may be used and disclosed, and how I can obtain access to this information.
Patient Name (Print): _____________________________________________
Patient Signature: ________________________________________________
Date: ________________________
If signing on behalf of patient, relationship: ____________________
Beautiful Smiles | Dr. Ben Stevens | 201 S. Emerson Ave Suite 130, Greenwood, IN 46143