Notice of Privacy Practices for Endodontic Care

Effective Date: [Insert Date]

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

Our Commitment to Your Privacy

Our endodontic 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.

How We May Use and Disclose Your Information

Treatment

• Consulting with other dental/medical professionals
• Scheduling appointments
• Providing root canal therapy and related procedures
• Prescribing medications

Payment

• Verifying insurance coverage
• Processing claims
• Collection activities

Healthcare Operations

• Quality assessment
• Employee review
• Training programs
• Licensing 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 Confidential Communications

Changes to This Notice

We reserve the right to change this notice at any time. The revised notice will be effective for all protected health information we maintain.

Contact Information

Practice Name: [Insert Name] Address: [Insert Address] Phone: [Insert Phone] Email: [Insert Email]

Acknowledgment

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

Patient Signature

Date