Privacy Notice


1. Your Information.

2, Your Rights.

3. Our Responsibilities.

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. (privacy notice PDF)

Your Rights

You have the right to:
  • get a copy of your paper or electronic medical record.
  • correct your paper or electronic medical record.
  • request confidential communication.
  • ask us to limit the information we share.
  • get a list of those with whom we've shared your information.
  • get a copy of this privacy notice.
  • choose someone to act lor you.
  • file a complaint if you believe your privacy rights have been violated.

Your Choices

You have some choices in the way that we use and share information as we:

  • tell family and friends about your condition.
  • provide disaster relief.
  • include you in a hospital directory.
  • market our services and sell your information.
  • raise funds.

Our Uses and Disclosures

We may use and share your information as we:

  • treat you.
  • run our organization.
  • bill for your services.
  • help with public health and safety issues.
  • do research.
  • comply with the law.
  • respond to organ and tissue donation requests.
  • work with a medical examiner or funeral director.
  • address workers' compensation, law enforcement, and other government requests.
  • respond to lawsuits and legal actions.

Our Responsibilities

  • We are required by law to maintain the privacy and security of your protected health information.
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • 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.

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 web site.

Other Information

  • We do not create or manage a hospital directory.
  • We do not create or maintain psychotherapy and./or substance abuse information at this practice.
  • We do not receive financial remuneration for marketing products or services in this practice.
  • We do not sell patient information in this practice.
  • We do not engage in fundraising at this practice.
  • We do not engage in research studies at this practice.
  • We may ask about HIV status because it is pertinent to your dental care but will make no further disclosure of such information without specific written consent from you or as otherwise required by law.
  • We will never share any psychotherapy, HIV or substance abuse records without your written permission. A general authorization for release of records is not sufficient for us to release this type of information. We will ask you to sign a separate written consent form that specifically mentions this type of information before we release this type of information. If you direct us to release this type of information, we will instruct the recipient that further disclosure by the recipient requires your specific written consent.
  • Under Florida law, we are unable to submit claims to payers (your health plan) under assignment of benefits without your signature on our Consent form. We will not condition treatment on your signing a Consent form but, unless you pay in full out-of-pocket, we may be forced to decline you as a new patient or discontinue you as an active patient if you choose not to sign the Consent or revoke it.
  • Effective Date of this Notice is Sept. 23,2013.

Questions and complaints

If you want more information about our privacy practices, have a question or have a concern about your personal information, please contact us as indicated below:

Our Privacy Official: Dr. Don J. Ilkka, DDS
Telephone: 352-787-4748
Fax: 352-326-8302
Address: 8301 CR 44, Leg A, Leesburg, FL 34788