This Notice of Privacy Practices (“Notice”) describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Protected health information (PHI) includes information that identifies you and relates to your past, present, or future physical or mental health or condition, the healthcare services you receive, or payment for those services.

Some types of health information, including records related to Substance Use Disorder (SUD), receive additional protections under federal law, including regulations found at 42 CFR Part 2, in addition to HIPAA. These enhanced protections are explained later in this Notice.

Our Pledge Regarding Your Health Information

We understand that your health information is personal and confidential. We are committed to protecting the privacy and security of your protected health information (PHI).

We are required by law to:

• Maintain the privacy of your PHI
• Provide you with this Notice of our legal duties and privacy practices
• Follow the terms of this Notice
• Notify you if a breach occurs that may have compromised the privacy or security of your information

How We May Use and Disclose Your PHI

Treatment
We may use and disclose your PHI to provide, coordinate, or manage your dental care and related services.

Payment
We may use and disclose your PHI to obtain payment for services provided to you.

Healthcare Operations
We may use and disclose your PHI for practice operations, including quality assessment, staff training, legal compliance, auditing, and business planning.

Appointment Reminders
We may use or disclose your PHI to contact you about appointments, reminders, or treatment alternatives.

Required by Law
We may use or disclose your PHI when required by federal, state, or local law.

Emergencies
We may use or disclose your PHI in emergency situations as necessary to protect your health or safety.

Public Health Activities
We may disclose PHI for public health purposes, including disease prevention and reporting.

Military, National Security, and Protective Services
We may disclose PHI as required for military activities, national security, and protective services.

Research
We may use or disclose your PHI for research purposes when approved by law and with appropriate safeguards.

Legal Proceedings
We may only disclose PHI in response to a valid court order or other lawful process or by your written consent.

Marketing
We will not use your PHI for marketing purposes without your written authorization.

Personal Representatives
We may only disclose your PHI to a personal representative authorized by you in writing.

Business Associates
We may share your PHI with business associates who perform services on our behalf. These business associates are required by law to safeguard your information.

Workers’ Compensation
We may disclose PHI for workers’ compensation or similar programs that provide benefits for work-related injuries or illness.

Special Protections for Substance Use Disorder (SUD) Records

Some health information is considered especially sensitive and receives enhanced protection under federal law, including information related to Substance Use Disorder (SUD).

Even if this practice is not a substance use treatment provider, these protections may apply if we receive, maintain, or transmit SUD-related information as part of your health record.

How SUD Information May Be Used
SUD-related records may be used and disclosed for treatment, payment, and healthcare operations, as permitted by law, unless you request additional restrictions.

Prohibition on Legal Use
SUD-related records may not be used against you in criminal, civil, or administrative proceedings without your written consent or a specific court order.

Redisclosure Limitations
SUD-related information may not be redisclosed unless permitted by law. Additional restrictions may apply beyond standard HIPAA rules.

Fundraising Restrictions
Your SUD-related information will not be used for fundraising purposes without your consent. You have the right to opt out of fundraising communications.

Your Rights Regarding Your Health Information

You have the right to:

• Access – Obtain a copy of your PHI
• Amendment – Request corrections to your PHI
• Accounting of Disclosures – Receive a list of certain disclosures of your PHI
• Restrictions – Request limitations on how we use or disclose your PHI
• Confidential Communications – Request communications in a specific manner/location
• Fundraising Opt-Out – Opt out of fundraising communications
• Breach Notification – Be notified of breaches of unsecured PHI
• Complaints – File a complaint with the Office for Civil Rights without retaliation

Changes to This Notice

We reserve the right to change this Notice. Any changes will apply to all PHI we maintain. The updated Notice will be available upon request, in our office, and on our website.

Patient Acknowledgment Contact Information

If you have questions, would like additional information, or wish to exercise your rights, please contact:

Practice Name:
Address:
Phone Number:
Email (Optional):

Patient Acknowledgment of Notice

By signing below, you acknowledge that you have received a copy of this Notice of Privacy Practices and understand your rights under HIPAA and applicable federal confidentiality laws, including special protections related to Substance Use Disorder (SUD) information.

☐ I acknowledge receipt of this Notice of Privacy Practices.

☐ I understand that SUD-related information may have additional protections.

☐ I understand my right to opt out of fundraising communications.

☐ I understand that certain disclosures may require my written authorization.

☐ Their SUD-related information cannot be used for fundraising without consent.

Patient Name (Print): ____________________________________

Signature: ____________________________________

Date: ____________________________________

If the patient is unable or unwilling to sign, staff should document the reason here.

Staff Initials: ____________________

Date: ____________________

If you believe your privacy rights have been violated, you may file a complaint with us or with OCR. You will not be penalized for filing a complaint.

Practice Privacy Officer:
Practice Address:
Phone Number:
Email (Optional):