HIPAA Notice of Privacy Practices
Effective date: [Month DD, YYYY]
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.
Ashar Dentistry is committed to protecting the privacy of your protected health information ("PHI"). We are required by law to maintain the privacy of your PHI, to provide you with this Notice of our legal duties and privacy practices, and to follow the terms of the Notice currently in effect.
How We May Use and Disclose Your Health Information
Treatment
We may use and disclose your PHI to provide, coordinate, or manage your dental care and related services — for example, sharing information with a specialist, laboratory, or another provider involved in your care.
Payment
We may use and disclose your PHI to obtain payment for services — for example, submitting claims to your dental insurance and providing information needed to determine eligibility or coverage.
Health Care Operations
We may use and disclose your PHI to run our practice — for example, quality assessment, staff training, scheduling, appointment reminders, and general administration.
Appointment Reminders & Communications
We may contact you (by phone, text, email, or mail, according to your preferences) to remind you of appointments or to share information about treatment options or services that may be of interest.
Other Uses and Disclosures Permitted or Required by Law
We may use or disclose your PHI without your authorization in certain situations, including: as required by law; for public health activities; to report abuse, neglect, or domestic violence; for health oversight activities; for judicial and administrative proceedings; for law enforcement purposes; to avert a serious threat to health or safety; for workers' compensation; and for specialized government functions, each subject to applicable legal conditions.
Uses and Disclosures That Require Your Written Authorization
Most uses and disclosures not described in this Notice — including most uses of psychotherapy notes (if any), uses for marketing, and any sale of PHI — will be made only with your written authorization. You may revoke an authorization in writing at any time, except to the extent we have already acted in reliance on it.
Your Rights Regarding Your Health Information
- Right to inspect and copy your PHI, subject to certain limitations;
- Right to request an amendment of PHI you believe is incorrect or incomplete;
- Right to an accounting of certain disclosures we have made;
- Right to request restrictions on certain uses and disclosures;
- Right to request confidential communications by alternative means or at an alternative location;
- Right to a paper copy of this Notice upon request, even if you agreed to receive it electronically;
- Right to be notified in the event of a breach of your unsecured PHI.
To exercise any of these rights, please contact our Privacy Officer using the information below.
Our Responsibilities
We are required to maintain the privacy of your PHI, provide this Notice of our duties and privacy practices, follow the terms of the Notice currently in effect, and notify you if a breach occurs that may have compromised the privacy or security of your information. We will not use or disclose your PHI other than as described here without your written authorization, except as permitted or required by law.
Changes to This Notice
We reserve the right to change this Notice and to make the revised Notice effective for PHI we already have as well as any information we receive in the future. The current Notice will be posted in our office and on this website with its effective date.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer or with the U.S. Department of Health and Human Services, Office for Civil Rights. You will not be retaliated against for filing a complaint.