HIPAA Notice of Privacy Practices

Effective Date: January 1, 2026

How We Use Your Health Information

We use and share your protected health information (PHI) in the following ways:

• Treatment — To provide, coordinate, and manage your dental care and related services.
• Payment — To bill and receive payment from you, your insurance company, or other third-party payers.
• Health Care Operations — For administrative, quality improvement, and operational purposes necessary to run our practice.

Your Rights Regarding Your Information

• Right to Access — You may request to inspect and receive a copy of your health records.
• Right to Amend — You may request corrections to your health information if you believe it is inaccurate or incomplete.
• Right to an Accounting — You may request a list of disclosures we have made of your health information.
• Right to Request Restrictions — You may ask us to limit how we use or share your information for treatment, payment, or operations.
• Right to Confidential Communications — You may request that we contact you in a specific way or at a specific location.
• Right to a Paper Copy — You may request a paper copy of this notice at any time.

Our Responsibilities

We are required by law to maintain the privacy of your protected health information, to provide you with this notice of our legal duties and privacy practices, to notify you if a breach occurs that may have compromised your information, and to follow the terms of this notice.

Complaints

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 Office for Civil Rights. We will not retaliate against you for filing a complaint.

Contact Our Privacy Officer

This notice is provided as a template. Consult a qualified healthcare attorney to ensure full HIPAA compliance before publishing.