The most common reason why we use or disclose your health information is for treatment, payment or health care operations.  Examples of how we use or disclose information for treatment purposes are:  setting up an appointment for you; examining your teeth; prescribing medications and faxing them to be filled; referring you to another doctor or clinic for other health care or services; or getting copies of your health information from another professional that you may have seen before us.  Examples of how we use or disclose your health information for payment purposes are:  asking you about your health or dental care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney).  “Health care operations” mean those administrative and managerial functions that we have to do in order to run our office.  Examples of how we use or disclose your health information for health care operations are:  financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records. We routinely use your health information inside our office for these purposes without any special permission.  If we need to disclose your health information outside of our office for these reasons, we usually will not ask you for special written permission.


In some limited situations, the law allows or requires us to use or disclose your health information without your permission.  Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:

  • When a state or federal law mandates that certain health information be reported for a specific purpose;
  • For public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices;
  • Disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;
  • Uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws;
  • Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
  • Disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else;
  • Disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations;
  • Uses or disclosures for health related research;
  • Uses and disclosures to prevent a serious threat to health or safety;
  • Uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service;
  • Disclosures of de-identified information;
  • Disclosures relating to worker’s compensation programs;
  • Disclosures of a “limited data set” for research, public health, or health care operations;
  • Incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
  • Disclosures to “business associates” who perform health care operations for us and who commit to respect the privacy of your health information;
  • Unless you object, we will also share relevant information about your care with your family or friends who are helping you with your dental care.


By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it.  We reserve the right to change this notice at any time as allowed by law.  If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future.  If we change our Notice of Privacy Practices, we will post the new notice in our office, have copies available in our office, and post it on our webpage at:


If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights.  We will not retaliate against you if you make a complaint.  If you want to complain to us, send a written complaint to the office contact person at the address or e-mail shown at the end of this Notice.  If you prefer, you can discuss your complaint in person or by phone at 417-447-8835.


If you want more information about our privacy practices, call or visit the office contact person at the address or phone number shown at the end of this Notice.


The law gives you many rights regarding your health information.

You can:

  • Ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want.  To ask for a restriction, send a written request to the office contact person at the address or   e-mail shown at the end of this Notice.
  • Ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using e-mail to your personal e-mail address. We will accommodate these requests if they are reasonable, and if you pay us for any extra cost.  If you want to ask for confidential communications, send a written request to the office contact person at the address or e-mail shown at the end of this Notice.
  • Ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying.  For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us (or sixty days if the information is stored off-site).  You may have to pay for photocopies in advance.  If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally available.  By law, we can have one 30-day extension of the time for us to give you access or photocopies if we send you a written notice of the extension.  If you want to review or get photocopies of your health information, send a written request to the office contact person at the address or e-mail shown at the end of this Notice.
  • Ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us.  We will send the corrected information to persons who we know got the wrong information, and others that you specify.  If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write.  Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information.  By law, we can have one 30-day extension of time to consider a request for amendment if we notify you in writing of the extension.  If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to the office contact person at the address or e-mail shown at the end of this Notice.
  • Get a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want). By law, the list will not include:  disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures.  You are entitled to one such list per year without charge.  If you want more than one list per year, you must pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law, we can have one 30-day extension of time if we notify you of the extension in writing.  If you want a list, send a written request to the office contact person at the address or e-mail shown at the end of this Notice.
  • Get additional paper copies of this Notice of Privacy Practices upon request. It does not matter whether you got one electronically or in paper form already.  If you want additional paper copies, send a written request to the address or e-mail shown at the end of this Notice.


The risks involved with local anesthesia include but are not limited to:

  1. Risks of anesthesia that may affect your body are dizziness, nausea, vomiting, accelerated heart rate, slow heart rate or various types of allergic reactions. (Please inform clinician if you have experienced adverse reactions to local anesthesia).
  2. Restricted mouth opening during recovery sometimes related to muscle soreness at the site of the injection.
  3. Local anesthesia may cause prolonged numbness; some patients may result in injury from biting or chewing an area such as lip, cheek or tongue that has received the local anesthesia.
  4. Injury to nerves that can result in pain, numbness, tingling or other sensory disturbances to the chin, lip, cheek, gums or tongue. This may persist for an extended length of time.

Local anesthesia is administered with a very fine needle; in very rare instances these may break.


In order to provide the optimal learning experience, you will be photographed and/or videotaped. These prints and recordings will be used for educational purposes only. Other students will be allowed to view such prints and recording at the discretion of the faculty and staff at Ozarks Technical Community College. The details of all experiences will be maintained as strictly confidential and used for educational purposes only.

I agree to give Ozarks Technical Community College the irrevocable right to use film and/or videotape reproduction (analog or digital) of my likeness without any restriction, and I waive any right to inspect or approve the finished version(s) incorporating the project, including written copy of broadcast copy that may be created and appear in connection therewith.  I/we hereby waive any claims I/we may have based on any usage of the tape or film products derived therefrom, including but not limited to claims for either invasion of privacy or libel.


  • Patients with a blood pressure greater than or equal to 160/95 will not be seen in the clinic. A referral letter will be sent for a medical consultation. The patient may be rescheduled in the clinic once the blood pressure is stabilized.
  • Certain medical conditions may require the patient take an antibiotic premedication prior to their dental appointment.
  • Patients may be asked to get a medical clearance from their physician before treatment is given.
  • Patients with diabetes must have taken their medicine and eaten prior to the dental appointment. Patients with blood sugar levels lower than 70 or greater than 180 will not be seen in the clinic.
  • Patients with asthma must have their inhaler with them during treatment in the clinic.
  • We require a 48-hour notice if you will be unable to keep your appointment for any reason, except in the case of inclement weather. If you fail to keep your appointment, or if you call to cancel with less than 48-hour notice, we will NOT reschedule your appointment.
  • If the patient does not speak English, they are responsible for bringing a translator to each appointment. The translator must be available and present for the entire duration of each appointment.