Keith Mann DDS - General Dentistry

Privacy Policy






We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice was effective 10/18/2004, was last updated 9/13/2013, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all protected health information that we maintain, including protected 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 make the new Notice available upon request.

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. It is always posted in the waiting room for your in office viewing and on our website for viewing at home.


We use and disclose protected health information (PHI) about you for treatment, payment, and healthcare operations. For example:

: We may use and disclose your PHI to a physician, specialist, laboratory, or other healthcare provider providing treatment to you. This may be done by phone, fax, letter, referral slip, or e-mail.

: We may use and disclose your PHI to obtain payment for services we provide to you. We may share your PHI with billing companies, insurance companies, health plans, government agencies, and collection agencies.

Healthcare Operations: We may use and disclose your PHI in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating employee and provider performance, assisting in resolving problems or complaints within the practice, conducting staff training programs, training students, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your PHI 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 this Notice.

To Your Family and Friends: We must disclose your PHI to you, as described in the Patient Rights section of this Notice. We may disclose your PHI 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 that we may do so.

Persons Involved In Care: We may use and disclose PHI 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 death. If you are present, then prior to use or disclosure of your PHI, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose PHI based on a determination using our professional judgment disclosing only PHI 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 prescriptions, dental supplies, x-rays, or other similar forms of PHI.

Marketing Health-Related Services, Fundraising, and the Sale of PHI: We will not use your PHI for marketing communications, fundraising or sell your PHI without your prior written authorization.

Required by Law: We may use and disclose your PHI when we are required to do so by law. This may include requests from police or other law enforcement agencies, public health agencies, health oversight agencies, coroners, medical examiners, funeral directors, or for legal proceedings, workers compensation claims or investigations, or disaster relief efforts.

Abuse or Neglect:
We may disclose your PHI 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 PHI 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 PHI 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 PHI to correctional institution or law enforcement official having lawful custody of an inmate or patient under certain circumstances.

Appointment Reminders:
We may use and disclose your PHI to provide you with appointment reminders (such as voicemail messages, postcards, e-mail, or letters). Please notify us in writing if you would like to opt out of any or all reminders.


Access: You have the right to look at or get copies of your PHI, with limited exceptions. You may request that we provide copies in paper or electronic format. We will use the format you request unless we cannot practicably do so.

Disclosure Accounting:
You have the right to receive a list of instances in which we or our business associates disclosed your PHI for purposes, other than treatment, payment, healthcare operations, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

You have the right to request that we place additional restrictions on our use and disclosure of your PHI. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). You also have the right to restrict the PHI that we share with your insurance company if you have paid in full for the service or product.

Alternative Communication:
You have the right to request that we communicate with you about your PHI by alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.
Amendment: You have the right to request that we amend your PHI. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances. You will have the opportunity to disagree if your request is denied.

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.
Notification in the Event of a Breach: In the event that your PHI has been compromised by this office or one of our business associates you will be notified by written notice and/or phone. If there is a large number of individuals affected, we will also post a notice on our website and notify prominent media outlets.


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 protected health information or in response to a request you made to amend or restrict the use or disclosure of your PHI or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. Their phone number is 404-562-7886.

We support your right to the privacy of your protected health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact Officer:
Keith W. Mann, DDS, PLLC
818-A Pine Grove Drive
Wilmington, NC 28409
(910) 397-9277
(910) 397-9137 fax