Notice of Privacy Practices for Periodontal Practice

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 Legal Duty

We are required by applicable federal and state law to maintain the privacy of your protected health information (PHI). We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your PHI.

Uses and Disclosures of Health Information

We may use and disclose your health information for:

• Treatment: Providing, coordinating, or managing your periodontal care
• Payment: Obtaining reimbursement for services, confirming coverage, billing activities
• Healthcare Operations: Business aspects of running our practice

Your Authorization

In addition to our use of your health information for treatment, payment, or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose.

Patient Rights

You have the right to:

1. Look at or get copies of your health information
2. Receive a list of instances where we disclosed your health information
3. Request restrictions on certain uses and disclosures
4. Request that we communicate with you about medical matters in a certain way
5. Receive a paper copy of this Notice

Questions and Complaints

If you want more information about our privacy practices or have questions or concerns, please contact us.

Practice Name: [INSERT NAME] Address: [INSERT ADDRESS] Phone: [INSERT PHONE] Email: [INSERT EMAIL]

By signing below, you acknowledge receipt of this Notice of Privacy Practices.

Signature: ___________________ Date: ___________________