Dental Practice Privacy Policy

Notice of Privacy Practices

Effective Date: [Date]

Our Commitment to Your Privacy

Our practice is dedicated to maintaining the privacy of your protected health information (PHI). We are required by law to maintain the confidentiality of your health information and provide you with this notice of our legal duties and privacy practices.

Information We Collect

• Dental and medical history
• Insurance and payment information
• Contact and demographic information
• Treatment records and x-rays
• Communication records between you and our practice

How We May Use and Disclose Your Information

Treatment

• Providing dental care and services
• Coordinating care with other healthcare providers
• Sending x-rays, records, or information to specialists

Payment

• Billing and collection activities
• Insurance verification and claims submission
• Payment processing

Healthcare Operations

• Quality assessment activities
• Employee review activities
• Training of dental students
• Licensing and credentialing activities

Your Rights Regarding Your Health Information

1. Right to Inspect and Copy
2. Right to Amend
3. Right to an Accounting of Disclosures
4. Right to Request Restrictions
5. Right to Request Confidential Communications
6. Right to a Paper Copy of This Notice

Changes to This Notice

We reserve the right to change this notice at any time. We will post a copy of the current notice in our facility.

Privacy Contact Information

For more information about our privacy practices, please contact: [Practice Privacy Officer] [Contact Information]

Acknowledgment

I acknowledge that I have received a copy of this Notice of Privacy Practices.

Patient/Guardian Signature

Date