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.
Who Follows This Notice
One Loose Tooth Dental, doing business as Mountain Dental, and all members of our workforce follow the terms of this notice. We may share information with each other for treatment, payment, and health care operations as described here.
Our Pledge Regarding Your Health Information
We understand that information about you and your health is personal, and we are committed to protecting it. We are required by law to maintain the privacy of your protected health information, to give you this notice of our legal duties and privacy practices, to follow the terms of the notice currently in effect, and to notify you if a breach of your unsecured health information occurs.
How We May Use and Disclose Your Health Information
The following describes the ways we may use and disclose your protected health information, with examples. Not every use or disclosure is listed, but every use and disclosure we make will fall within one of these categories.
- Treatment. We may use and disclose your health information to provide, coordinate, or manage your dental care, including sharing information with other providers involved in your treatment, such as specialists, laboratories, or your physician.
- Payment. We may use and disclose your health information to obtain payment for the services we provide, such as billing and collecting from you, your dental plan, or your insurer, and confirming coverage and benefits.
- Health care operations. We may use and disclose your health information for operations such as quality assessment and improvement, training, licensing, business management, and general administrative activities.
- Appointment reminders. We may contact you to remind you of an upcoming appointment.
- Treatment alternatives and health-related benefits. We may tell you about treatment options or health-related products and services that may be of interest to you.
- Individuals involved in your care. We may share information with a family member, friend, or other person you identify who is involved in your care or payment for your care, to the extent permitted by law.
- Business associates. We may disclose information to vendors who perform services for us and who agree to protect it.
- As required by law. We will disclose your health information when federal, state, or local law requires it.
- Public health and safety. We may disclose information for public health activities, to report abuse or neglect, for health oversight activities, and to prevent a serious threat to health or safety.
- Legal proceedings and law enforcement. We may disclose information in response to a court or administrative order, subpoena, or other lawful process, and for certain law enforcement purposes.
- Other permitted disclosures. We may disclose information to coroners, medical examiners, and funeral directors, for organ donation, for approved research, for workers’ compensation, for specialized government functions such as military and veterans’ activities, and for correctional institutions, each as permitted by law.
Uses and Disclosures That Require Your Written Authorization
Other uses and disclosures not described in this notice will be made only with your written authorization. This includes most uses and disclosures of psychotherapy notes if any are maintained, uses and disclosures for marketing, and any disclosure that is a sale of your health information. You may revoke an authorization in writing at any time, except to the extent we have already relied on it.
California-Specific Protections
California law, including the Confidentiality of Medical Information Act, may provide additional protections for certain categories of information, such as mental health, HIV status, and substance use treatment. [Counsel to confirm and add any California-specific language required for a dental practice.]
Your Rights Regarding Your Health Information
You have the following rights regarding the health information we maintain about you:
- Right to inspect and copy. You may inspect and obtain a copy of your health information, including an electronic copy of electronically maintained records, subject to limited exceptions.
- Right to request an amendment. You may ask us to amend information you believe is incorrect or incomplete. We may deny the request in certain cases and will explain why.
- Right to an accounting of disclosures. You may request a list of certain disclosures we have made of your health information.
- Right to request restrictions. You may ask us to limit how we use or disclose your information. We are not required to agree, except that we must agree to a request to restrict disclosure to a health plan for a service you paid for in full out of pocket.
- Right to confidential communications. You may ask us to contact you in a specific way or at a specific location.
- Right to a paper copy. You may obtain a paper copy of this notice at any time, even if you agreed to receive it electronically.
- Right to be notified of a breach. You have the right to be notified if a breach of your unsecured health information occurs.
Our Responsibilities
We are required to maintain the privacy of your health information, to provide this notice describing our duties and privacy practices, and to follow the terms of the notice currently in effect. We will not use or share your information other than as described here unless you tell us we can in writing.
Changes to This Notice
We reserve the right to change this notice and to make the revised notice effective for health information we already have as well as any information we receive in the future. The current notice will be posted in our office and on our website, and will include its effective date.
How to File a Complaint
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the U.S. Department of Health and Human Services, Office for Civil Rights. To file a complaint with us, contact [HIPAA Privacy Officer name, title, phone, and email]. You will not be penalized or retaliated against for filing a complaint.
Acknowledgment
We may ask you to sign an acknowledgment that you received this notice.
For More Information
For more information about this notice or our privacy practices, contact [HIPAA Privacy Officer name, title, phone, and email].
Mountain Dental
596 Main Street, Placerville, CA 95667
Phone: (530) 642-8614