HIPAA Policy Practices

Southern Roots Endodontics

HIPAA Notice of Privacy Practices

For Endodontic Patients

Effective Date: 10/06/2026

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.

Your Information. Your Rights. Our Responsibilities.

This notice applies to Southern Roots Endodontics and its dentists, employees, and other workforce members. It covers protected health information in paper, electronic, and oral form, including dental and medical histories, endodontic treatment records, radiographs, CBCT images, prescriptions, referrals, and billing information.

This HIPAA notice is separate from our Website Privacy Policy, which describes general website information practices. Simply viewing our website does not constitute authorization to use or disclose your protected health information.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an Electronic or Paper Copy of Your Dental and Medical Records

• You      can ask to see or get an electronic or paper copy of your dental and      medical records and other health information we have about you. Ask us how      to do this.
• We      generally act on access requests within 30 days. If a legally permitted      extension is needed, we will notify you in writing of the reason and      expected completion date. We follow any applicable shorter legal deadline.
• We      provide records in the requested form and format when readily producible,      or agree with you on an alternative. A summary is provided only if you      agree in advance, including to any applicable fee.
• We may      charge a reasonable, cost-based copying fee permitted by law. Inspection      itself is free. Ask our office about requests to send copies to another      person; applicable legal requirements depend on the request.
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Inspect Your Records In Person

• You      may request to inspect your protected health information in person at our      dental office.
• During      an in-person inspection, you may take notes or photographs of your own      health information. We will not impose unreasonable measures on your      ability to do so.

Ask Us to Correct Your Dental and Medical Records

• You      can ask us to correct health information about you that you think is      incorrect or incomplete. Ask us how to do this.
• We      generally respond within 60 days. If a legally permitted extension is      needed, we will explain it in writing. If we deny your request, we will      explain the reason and how you may submit a statement of disagreement.

Request Confidential Communications

• You      can ask us to contact you in a specific way (for example, home or office      phone) or to send mail to a different address.
• We      will say “yes” to all 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 our operations.
• We      are not required to agree to your request, and we may say “no” if it would      affect your care.
• If      you pay for a service or health care item out-of-pocket in full, you can      ask us not to share that information for the purpose of payment or our      operations with your health insurer.
• We      will say “yes” unless a law requires us to share that information.

Get a List of Certain Disclosures

• You      may request an accounting of certain disclosures made during the six years      before your request, or a shorter period you specify.
• The      accounting excludes treatment, payment, healthcare operations, disclosures      you authorized, and other legally excluded categories.
• The      first accounting in a 12-month period is free. For additional requests      within that period, we may charge a reasonable, cost-based fee after      notifying you and giving you an opportunity to withdraw or modify the      request.
• Contact      our Privacy Officer to make a request. We generally respond within 60      days, with a written explanation if a legally permitted extension is      necessary.

Get a Copy of This Privacy Notice

• You      can ask for a paper copy of this notice at any time, even if you have      agreed to receive the notice electronically. We will provide you with a      paper copy promptly.

Choose Someone to Act for You

• If      you have given someone medical power of attorney or if someone is your      legal guardian, that person can exercise your rights and make choices      about your health information.
• We      will make sure the person has this authority and can act for you before we      take any action.

File a Complaint If You Feel Your Rights Are Violated

• You      can complain if you feel we have violated your rights by contacting us      using the information on the last page of this notice.
• You      can file a complaint with the U.S. Department of Health and Human Services      Office for Civil Rights by sending a letter to 200 Independence Avenue,      S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting HHS      Gov.
• We      will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In These Cases, You Have Both the Right and Choice to Tell Us To:

• Share      information with your family, close friends, or others involved in your      care
• Share      information in a disaster relief situation

If you are not able to tell us your preference, for example, if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

Uses That Generally Require Written Authorization

• Marketing      uses and disclosures requiring authorization under HIPAA
• Sale      of protected health information requiring authorization under HIPAA
• Most      uses and disclosures of psychotherapy notes, if we receive or maintain      them

Other uses and disclosures not described in this notice require your written authorization unless otherwise permitted or required by law. You may revoke an authorization in writing at any time, except to the extent we have already relied on it or another legal exception applies. Consent or authorization requirements for Part 2 records are also explained below.

Fundraising

We may contact you for fundraising efforts, but you can tell us not to contact you again. If we create or maintain substance use disorder records protected under 42 CFR Part 2, we will provide you with a clear and conspicuous opportunity to opt out of fundraising communications before using or disclosing such records for that purpose.

Special Protections for Certain Types of Information

Some information, including certain HIV or sexually transmitted infection records, mental health records, genetic information, and substance use disorder treatment records, may have additional protections under Tennessee or federal law. Where those protections apply, we follow the more protective requirements, including obtaining specific permission or limiting disclosures as required. For example, Tennessee law restricts disclosure of covered HIV/sexually transmitted disease records and allows disclosure only with appropriate written permission or a legally permitted exception.

Substance Use Disorder (SUD) Treatment Information

Federal law (42 CFR Part 2) provides additional privacy protections for records relating to substance use disorder diagnosis, treatment, or referral created by federally assisted programs. Southern Roots Endodontics may receive these records as part of your health history or through coordination of care with other providers.

If we receive information about you from a substance use disorder treatment program covered by 42 CFR Part 2 (a “Part 2 Program”) through a general consent you gave that program for treatment, payment, and/or health care operations, we may use and share your record for those same purposes as explained in this Notice. If we receive your record with a specific consent that limits how it may be used, we will only use and share the information as expressly permitted in that consent.

**Restrictions on Use in Legal Proceedings: **Substance use disorder treatment records received from programs subject to 42 CFR Part 2, or testimony relaying the content of such records, shall not be used or disclosed in civil, criminal, administrative, or legislative proceedings against you unless based on your written consent, or a court order issued after notice and an opportunity to be heard is provided to you or the holder of the record, as provided in 42 CFR Part 2. A court order authorizing use or disclosure must be accompanied by a subpoena or other legal requirement compelling disclosure before the requested record is used or disclosed.

**Consent: **With certain exceptions, substance use disorder records come with a patient consent form permitting the Part 2 Program to disclose the patient’s information. A patient may provide a single consent for all future uses or disclosures for treatment, payment, and health care operations purposes. You may revoke consent in writing, subject to applicable law and actions already taken in reliance on that consent. A history of substance use in an ordinary dental record does not, by itself, make the record a Part 2 record.

Notice Regarding Redisclosure

Information that we disclose pursuant to this Notice or with your authorization may be subject to redisclosure by the recipient and may no longer be protected by the HIPAA Privacy Rule. However, substance use disorder treatment records protected under 42 CFR Part 2 have additional restrictions on redisclosure. Any re-disclosure of Part 2 records must comply with the requirements of that regulation.

Our Uses and Disclosures

We typically use or share your health information in the following ways.

Treat You

We can use your health information and share it with other professionals who are treating you.

Example: We share your examination findings, dental images, and root canal treatment report with your referring dentist or another provider involved in your care.

Run Our Organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We review endodontic treatment records for quality improvement, staff training, and practice administration. Vendors that handle protected health information on our behalf must meet applicable business associate requirements.

Bill for Your Services

We can use and share your health information to bill and get payment from health plans or other entities.

Example: We send your insurer information about a root canal evaluation or treatment to process a claim, subject to any required restriction for services you paid for in full out of pocket.

We may contact you about appointments, follow-up care, treatment alternatives, or health-related services as permitted by law. You may request reasonable confidential communication arrangements.

How Else Can We Use or Share Your Health Information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.

Note: Where uses or disclosures described in this Notice are limited by other applicable laws that are more stringent than HIPAA, including but not limited to 42 CFR Part 2 (governing substance use disorder records) and applicable state laws, we will comply with the more restrictive requirements of those laws.

Help with Public Health and Safety Issues

• Preventing      disease
• Helping      with product recalls
• Reporting      adverse reactions to medications
• Reporting      suspected abuse, neglect, or domestic violence
• Preventing      or reducing a serious threat to anyone’s health or safety

Do Research

We may use or disclose information for research only when applicable legal requirements, such as authorization or an approved waiver, are satisfied.

Comply with the Law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to Organ and Tissue Donation Requests

We can share health information about you with organ procurement organizations.

Work with a Medical Examiner or Funeral Director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address Workers’ Compensation, Law Enforcement, and Other Government Requests

We can use or share health information about you:

• For      workers’ compensation claims
• For      law enforcement purposes or with a law enforcement official
• With      health oversight agencies for activities authorized by law
• For      special government functions such as military, national security, and      presidential protective services

Respond to Lawsuits and Legal Actions

We may disclose health information in response to a court or administrative order or a subpoena only when the applicable legal requirements are met. A subpoena alone does not automatically authorize every disclosure. Additional restrictions apply to Part 2 records and other specially protected information.

Our Responsibilities

• We      are required by law to maintain the privacy and security of your protected      health information.
• We      will notify you if a breach of unsecured protected health information      requires notification under applicable law, without unreasonable delay and      within the legally required timeframe.
• We      must follow the duties and privacy practices described in this notice and      give you a copy of it.
• We      will not use or share your information other than as described here unless      you tell us we can in writing. If you tell us we can, you may change your      mind at any time. Let us know in writing if you change your mind.
• For      substance use disorder records protected under 42 CFR Part 2 that we      create or maintain, we have a duty to provide you with adequate notice of      how those records may be used and disclosed, and of your rights with      respect to such records.
• We      follow applicable Tennessee confidentiality requirements when they provide      greater protection than HIPAA.

Changes to the Terms of This Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.

Contact Information

To ask questions, request records, exercise a privacy right, or file a complaint, contact:

Privacy Officer — Southern Roots Endodontics

5221 Port Royal Road, Suite 302
Spring Hill, TN 37174
Phone: (615) 615-ROOT (7668)
Email: info@southernrootsendo.com
Website: southernrootsendo.com

Contact our office for any required request form and instructions. Please do not send sensitive health information through a general website form or ordinary email; ask us for a secure method.