Notice of Privacy Practices

Effective date: [CONFIRM — date this notice takes effect]

Our Commitment to Your Privacy

Watsonville Endodontics is required by law to maintain the privacy of your protected health information ("PHI"), to provide you with this notice describing our legal duties and privacy practices regarding PHI, and to abide by the terms of this notice while it is in effect.

How We May Use and Disclose Your Health Information

The following categories describe the ways we may use and disclose your PHI. Not every use or disclosure in a category is listed; however, all the ways we are permitted to use and disclose information fall within one of these categories.

Treatment

We may use and disclose your PHI to provide, coordinate, or manage your dental care. For example, we may share information about your treatment with your referring general dentist, or with another specialist involved in your care.

Payment

We may use and disclose your PHI to obtain payment for services we provide to you. For example, we may share information with your dental insurance plan so that it will pay us or reimburse you for treatment.

Health Care Operations

We may use and disclose your PHI for our own operations to facilitate the function of our practice and as necessary to provide quality care. For example, we may use health information to review the quality of care we provide, or for staff training.

Other Permitted or Required Uses and Disclosures

We may also use or disclose your PHI, without your written authorization, in the following situations:

• As required by law — when federal, state, or local law requires disclosure.
• Public health activities — for example, reporting to public health authorities as required.
• Health oversight activities — such as audits, investigations, or inspections by a health oversight agency.
• Judicial and administrative proceedings — in response to a court order or, in certain circumstances, a subpoena.
• Law enforcement purposes — under limited circumstances required or permitted by law.
• To avert a serious threat to health or safety — when necessary to prevent a serious threat to your health and safety or the health and safety of the public.
• Business associates — we may disclose PHI to contractors and business associates (for example, [CONFIRM — list any labs, billing services, or IT vendors that would qualify]) who perform services on our behalf and agree in writing to protect it.

Uses That Require Your Written Authorization

Other than as described above, we will not use or disclose your PHI without your written authorization. This includes, for example, most uses and disclosures of psychotherapy notes (not typically applicable to this practice), uses for marketing purposes, and disclosures that constitute a sale of PHI. You may revoke an authorization at any time in writing, except to the extent we have already acted in reliance on it.

Your Rights Regarding Your Health Information

• Right to Inspect and Copy — You have the right to inspect and obtain a copy of your PHI, with certain exceptions. Requests must be made in writing to our office.
• Right to Amend — You have the right to request that we amend your PHI if you believe it is incorrect or incomplete. We may deny the request under certain circumstances.
• Right to an Accounting of Disclosures — You have the right to request a list of certain disclosures we've made of your PHI, other than for treatment, payment, health care operations, and certain other exceptions.
• Right to Request Restrictions — You have the right to request a restriction on certain uses and disclosures of your PHI. We are not required to agree to a requested restriction, except in certain cases involving disclosures to a health plan when you have paid in full out of pocket.
• Right to Request Confidential Communications — You have the right to request that we communicate with you about your health information in a certain way or at a certain location (for example, by phone rather than mail).
• Right to a Paper Copy of This Notice — You have the right to obtain a paper copy of this notice at any time, even if you agreed to receive it electronically.
• Right to Be Notified of a Breach — You have the right to be notified in the event of a breach of your unsecured PHI.
• Right to File a Complaint — If you believe your privacy rights have been violated, you may file a complaint with our office or with the U.S. Department of Health and Human Services. You will not be retaliated against for filing a complaint.

Our Responsibilities

We are required by law to maintain the privacy and security of your protected health information, notify you promptly if a breach occurs that may have compromised the privacy or security of your information, follow the duties and privacy practices described in this notice, and give you a copy of it.

Changes to This Notice

We reserve the right to change this notice and to make the revised notice apply to PHI we already have as well as any information we receive in the future. The current notice will be available at our office and on this page.

How to File a Complaint

You may file a complaint with us by contacting [CONFIRM — name/title of practice Privacy Officer] at (831) 536-5295, 390 S. Green Valley Rd #7, Watsonville, CA 95076.

You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, by mail at 200 Independence Avenue SW, Room 509F, HHH Building, Washington, D.C. 20201, by phone at 1-800-368-1019, or online at ocrportal.hhs.gov.

Contact Information

Watsonville Endodontics, 390 S. Green Valley Rd #7, Watsonville, CA 95076 · (831) 536-5295