Notice of Privacy Practices for Oral Surgery

Effective Date: [INSERT DATE]

Our Commitment to Your Privacy

At [Practice Name], we are committed to maintaining the privacy of your protected health information (PHI). This Notice describes how medical information about you may be used and disclosed and how you can access this information.

Our Legal Duty

We are required by law to:

• Maintain the privacy of your protected health information
• Provide you with this Notice of our legal duties and privacy practices
• Follow the terms of this Notice currently in effect

How We May Use and Disclose Your Health Information

Treatment

• Share information with other healthcare providers involved in your care
• Coordinate services with other oral surgeons or specialists
• Contact you about appointment reminders

Payment

• Bill and collect payment from you, your insurance company, or other third parties
• Verify insurance coverage and benefits

Healthcare Operations

• Conduct quality assessment activities
• Review the competence of healthcare professionals
• Manage business operations

Your Rights Regarding Your Health Information

1. Right to Inspect and Copy

   • You have the right to inspect and obtain copies of your health information

2. Right to Amend

   • You may request amendments to your health information

3. Right to an Accounting of Disclosures

   • You may request a list of instances where we disclosed your information

4. Right to Request Restrictions

   • You may request limitations on how we use your information

Changes to This Notice

We reserve the right to change this Notice. Any revised Notice will be effective for information we already have about you as well as any information we receive in the future.

Contact Information

For more information about our privacy practices, please contact:

[Practice Name] Attn: Privacy Officer [Address] [Phone Number] [Email]