NOTICE OF PRIVACY PRACTICES
Effective Date: [02/16/2026]
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.
OUR RESPONSIBILITIES
We are required by law to:
Maintain the privacy of your protected health information (PHI)
Provide you with this Notice of our legal duties and privacy practices
Follow the terms of the Notice currently in effect
HOW WE MAY USE AND DISCLOSE YOUR INFORMATION
For Treatment
We may use or share your health information to provide, coordinate, or manage your dental care.
Example: Sharing X-rays with a specialist or another dentist involved in your care.
For Payment
We may use or share your information to bill and receive payment for services.
Example: Submitting claims to insurance or contacting you about balances.
For Health Care Operations
We may use or share your information to run our practice, improve quality, and train staff.
Example: Internal audits, training, quality improvement.
OTHER PERMITTED USES AND DISCLOSURES
We may also use or share your information:
- As required by law
- For public health activities
- To prevent or reduce a serious threat to health or safety
- For workers’ compensation or law enforcement purposes, as allowed by law
SPECIAL PROTECTIONS FOR CERTAIN INFORMATION (Part 2 / SUD Records)
If our practice maintains records related to substance use disorder (SUD) treatment, those records receive additional protections under federal law.
- If such information is received under a general authorization that permits use and disclosure for treatment, payment, or health care operations, as described above, we will use the information for some or all of those purposes.
- If such information is received under a specific authorization, we will use and disclose only as allowed under that specific authorization.
- Such information will not be shared without your written authorization, except as permitted or required by law.
- Once shared with your written consent, the information may be redisclosed by HIPAA entities, in accordance with HIPAA regulations.
- Such information, if de-identified, may be disclosed to public health authorities without your written consent.
YOUR RIGHTS
You have the right to:
✔ Get a Copy of Your Records
You may request access to our copies of your dental records. We may charge a reasonable fee.
✔ Request Corrections
If you believe information is incorrect or incomplete, you may request an amendment.
✔ Request Confidential Communications
You can ask us to contact you in a specific way (e.g., phone instead of mail).
✔ Request Restrictions
You may request limits on how your information is used or shared. We are not required to agree in all cases.
✔ Get a List of Disclosures
You can request a list of certain disclosures we have made.
✔ Receive a Paper Copy of This Notice
You may request a paper copy at any time.
OUR USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION
We will not use or disclose your information for purposes such as marketing or sharing with third parties without your written authorization, unless permitted by law.
You may revoke an authorization at any time in writing.
CHANGES TO THIS NOTICE
We reserve the right to change this Notice and make the revised Notice effective for information we already have. The updated Notice will be posted in our office and on our website (if applicable).
COMPLAINTS
If you believe your privacy rights have been violated, you may:
File a complaint with our office
File a complaint with the U.S. Department of Health and Human Services
You will not be retaliated against for filing a complaint.
CONTACT INFORMATION
Privacy Officer: Human Resources
Phone: (480) 626-4118
Email: HR@signaturedentalpartners.com
Office Address: 20445 Pacifica Drive, CA, USA 95014
