Periodontal Practice Privacy Policy

Notice of Privacy Practices

Effective Date: [Date]

Our Commitment to Your Privacy

Our periodontal practice is committed to maintaining the privacy of your protected health information (PHI). This notice describes how we collect, use, and disclose your medical information.

Information We Collect

• Dental and medical histories
• Treatment records and photographs
• X-rays and diagnostic images
• Insurance and payment information
• Contact and demographic information

Use and Disclosure of Information

We may use your PHI for:

Treatment

• Planning and providing dental care
• Consulting with other healthcare providers
• Scheduling appointments

Payment

• Billing and collection activities
• Insurance verification
• Claims processing

Healthcare Operations

• Quality assessment
• Staff training
• Business planning

Your Rights

You have the right to:

1. Access your health information
2. Request restrictions on PHI disclosure
3. Receive confidential communications
4. Amend your health records
5. Receive breach notifications

Security Measures

We implement appropriate physical, technical, and administrative safeguards to protect your information.

Contact Information

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

Changes to This Notice

We reserve the right to revise this notice. Current versions will be posted in our office and available upon request.

Acknowledgment

I acknowledge receipt of this Notice of Privacy Practices:

Signature: _________________ Date: _____________________