NOTICE OF PRIVACY PRACTICES

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.

Effective Date: ___2026_________

This Notice of Privacy Practices describes how our dental office may use and disclose your protected health information (PHI) and your rights regarding that information.

OUR RESPONSIBILITIES

Suggested text: When visitors leave comments on the site we collect the data shown in the comments form, and We are required by law to maintain the privacy of your health information, provide you with this notice of our legal duties and privacy practices, and follow the terms of this notice.

USES AND DISCLOSURES OF HEALTH INFORMATION

We may use or disclose your health information for the following purposes:

• Treatment: To provide, coordinate, or manage your dental care.
• Payment: To obtain payment for services provided to you.
• Healthcare Operations: For office operations such as quality assessment, training, licensing, and audits.

We may also use or disclose your information as required by law, for public health activities, to report abuse or neglect, for health oversight activities, for legal proceedings, or to avert a serious threat to health or safety.

OTHER USES AND DISCLOSURES

Any other use or disclosure of your health information not listed above will be made only with your written authorization. You may revoke your authorization in writing at any time.

YOUR RIGHTS
You have the right to:
• Inspect and obtain a copy of your health records
• Request corrections to your records
• Request restrictions on certain uses or disclosures
• Request confidential communications
• Receive an accounting of disclosures
• Obtain a paper copy of this notice

CHANGES TO THIS NOTICE

We reserve the right to change the terms of this notice and make the new notice effective for all PHI we maintain. A revised notice will be available upon request.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with our office or with the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint.

CONTACT INFORMATION

Practice Name: ___________________________
Privacy Officer: ___________________________
Phone Number: ___________________________
Address: _________________________________

ACKNOWLEDGMENT OF RECEIPT

I acknowledge that I have received a copy of this Notice of Privacy Practices.Patient Name: ____________________________
Signature: _______________________________
Date: ___________________________________