HIPAA Privacy Policy

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. 

For purposes of this Notice, “we,” “our,” and “us” refer to the health care facility named above. “You” and “your” refer to our patients or their authorized legal representatives. We are committed to protecting the privacy of your Protected Health Information (PHI). We follow the Health Insurance Portability and Accountability Act (HIPAA), its implementing regulations, and all amendments, including the 2026 revisions concerning Substance Use Disorder (SUD) treatment information governed by 42 CFR Part 2. 

OUR RESPONSIBILITIES

We are required to: 

• Maintain the privacy of your PHI, including SUD information that may carry extra confidentiality protections under 42 CFR Part 2. 
• Provide you with this Notice of our legal duties and privacy practices. 
• Notify you following a breach of unsecured PHI. 
• Follow the terms of this Notice. 

HOW WE MAY USE AND DISCLOSE YOUR PHI WITHOUT YOUR WRITTEN AUTHORIZATION: 

• Treatment: We may use and share your PHI with other dentists, physicians, or health care professionals who are treating you. Example: We send x-rays to a specialist for a consultation. 
• Payment: We may use and share your PHI to bill and get payment from health plans or other entities. Example: We submit information to your dental plan to obtain payment. 
• Health care operations: We may use and share your PHI to run our practice, improve your care, and contact you when necessary. Example: Quality assessment, auditing, or customer service. 
• Public health and safety: We may share PHI for public health reporting, to report abuse or neglect, to avert a serious threat to health or safety, or for product recalls, as permitted by law. 
• Health oversight and law enforcement: We may share PHI with health oversight agencies, for law enforcement purposes, or as required by a court or administrative order, subpoena, or similar process, as permitted by law. 
• Research: We may use or share PHI for research under specific conditions approved by an Institutional Review Board or privacy board, or with your authorization. 
• Workers’ compensation and other government functions: We may share PHI. for workers’ compensation claims and for specialized government functions as permitted by law 
• Business associates: We may share PHI with third parties who provide services for us (business associates) under contracts requiring them to protect your information. 

COMPLIANCE SOLUTIONS 11441 v001 02/2026 2 USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION: 

• Most uses and disclosures of psychotherapy notes (if any). 
• Marketing communications, sales of PHI, and other uses not described in this Notice. 
• Sharing your PHI for purposes not permitted by law without your written permission. 

YOUR RIGHTS REGARDING YOUR PHI: 

• Right to access: You can ask to see or get an electronic or paper copy of your dental record and other PHI we have about you. We will provide a copy or a summary of your health information within required time frames and may charge a reasonable, cost-based fee. 
• Right to request an amendment: You can ask us to correct information you think is incorrect or incomplete. We may say “no,” but we will tell you why in writing within 60 days. 
• Right to request restrictions: You can ask us not to use or share certain PHI for treatment, payment, or health care operations. We are not required to agree, except when you pay out-of-pocket in full and request that we not share information with your health plan for that service. 
• Right to request confidential communications: You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address 
• Right to an accounting of disclosures: You can ask for a list of certain disclosures we have made of your PHI for the six years prior to your request.
• Right to a paper copy of this Notice: You can ask for a paper copy of this Notice at any time 
• Right to choose a personal representative: If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information, consistent with applicable law. 

OUR DUTIES: 

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

SPECIAL NOTICE ABOUT SUBSTANCE USE DISORDER (SUD) RECORDS (42 CFR PART 2): 

If we create, maintain, or receive SUD records protected by 42 CFR Part 2, those records are subject to additional protection. Part 2 prohibits us from using or disclosing SUD records for many purposes without your written consent, including certain treatment, payment, and health care operations. Part 2 records generally may not be used or disclosed in civil, criminal, administrative, or legislative proceedings against you without your written consent or a specific court order. You may revoke your consent as permitted by Part 2. We may combine this notice with Part 2 Patient Notice so long as all required elements are included.