Orthodontic Practice Privacy Policy

Notice of Privacy Practices

Effective Date: [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.

Information We Collect

• Personal identification details
• Medical and dental history
• Treatment records and photographs
• X-rays and diagnostic images
• Insurance and payment information
• Treatment plans and progress notes

How We May Use and Disclose Your Information

For Treatment

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

For Payment

• Billing and collection activities
• Insurance claim submission
• Verification of coverage

For Healthcare Operations

• Quality assessment
• Staff training
• Business planning

Your Rights Regarding Your Information

1. Right to inspect and copy records
2. Right to amend incorrect information
3. Right to receive an accounting of disclosures
4. Right to request restrictions
5. Right to confidential communications

Our Responsibilities

• Maintain privacy of your health information
• Notify you of our legal duties and privacy practices
• Follow terms of this notice
• Obtain your authorization for other uses

Changes to This Notice

We reserve the right to change this notice. Any revisions will apply to all records maintained by our practice.

Contact Information

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

Acknowledgment

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

Signature: _________________ Date: _____________________