Notice of Privacy Practices for Orthodontic Care

Effective Date: [DATE]

Our Commitment to Your Privacy

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

Understanding Your Health Information

Each time you visit our orthodontic practice, we create a record of your visit. This record typically contains:

• Your personal identification information
• Medical and dental history
• Examination results
• Treatment plans and procedures
• X-rays and photographs
• Financial and insurance information

How We May Use and Disclose Your Information

For Treatment

• Consulting with other healthcare providers
• Scheduling appointments
• Providing follow-up care instructions

For Payment

• Verifying insurance coverage
• Processing claims
• Collection activities

For Healthcare Operations

• Quality assessment
• Employee review activities
• Training programs
• Licensing and credentialing

Your Health Information Rights

You have the right to:

1. Request restrictions on certain uses
2. Receive confidential communications
3. Inspect and copy your health record
4. Amend your health record
5. Receive an accounting of disclosures
6. Obtain a paper copy of this notice

Our Responsibilities

We are required to:

• Maintain privacy of your health information
• Provide notice of our legal duties and privacy practices
• Abide by the terms of this notice
• Notify you if we cannot accommodate requested restrictions

Contact Information

Privacy Officer: [NAME] Phone: [PHONE] Address: [ADDRESS]

Acknowledgment

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

Signature: _________________ Date: _____________________