Dental Practice Notice of Privacy Practices

Understanding Your Health Information Rights

This notice describes how medical and dental information about you may be used and disclosed and how you can access this information. Please review it carefully.

Your Rights

You have the right to:

• Obtain a copy of your paper or electronic dental records
• Request corrections to your dental records
• 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 for you
• File a complaint if you believe your privacy rights have been violated

Our Uses and Disclosures

We may use and share your information as we:

• Treat you
• Run our dental practice
• Bill for your services
• Help with public health and safety issues
• Conduct research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with medical examiners
• Address workers' compensation, law enforcement, and other government requests

Your Choices

For certain health information, you can tell us your choices about what we share. You have the right to tell us to:

• Share information with your family, friends, or others involved in your care
• Share information in a disaster relief situation

Our Responsibilities

We are required by law to:

• Maintain the privacy and security of your protected health information
• Inform you promptly if a breach occurs that may compromise your information
• Follow the duties and privacy practices described in this notice
• Give you a copy of this notice

Contact Information

[Practice Name] Address: [Street, City, State, ZIP] Phone: [Phone Number] Email: [Email Address]

Effective Date

This notice is effective as of [Date]