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Notice of
Privacy Practices

Effective October 15, 2023



We are required by law to give you this Notice to inform you of how we may use and disclose your protected health information and describes your rights and our obligations regarding the use and disclosure of that information. We will maintain the privacy of protected health information and provide you with notice (“Notice”) of our legal duties and privacy practices with respect to your protected health information.

We have the right to change this Notice at any time. If we change this Notice, the new notice will apply to all your future, current and past health information. If we change this Notice, we will post the new notice in our office, have copies available in our office and post it to our website.


We may disclose or use your health information for certain purposes, some of which are included below. Please be advised that not every use or disclosure will be listed.

Treatment, Payment and Healthcare Operations: The most common reason why we use or disclose your health information is for treatment, payment or healthcare operations without your authorization.

Treatment: We may use and disclose your information to treat you. This includes disclosing your protected health information to: other dentists, hygienist, medical providers, trainees and office staff that are involved in your health care; schedule an appointment for you; perform an examination on you; prescribe medications or send them to be filled; refer you to or consult with another healthcare provider to coordinate your care; or get copies of your information from another healthcare provider that you may have seen before.

Payment: We may use or disclose your information to obtain payment for services that we provide for you. For example, we may use or disclose your information to: ask you or your insurance company about your health insurance coverage or other sources of payment; to prepare and send bills or claims; or to collect unpaid amounts (either ourselves or through a collection agency or attorney).

Healthcare Operations: We may use or disclose your protected health information in order to operate this medical practice. These activities include to train or evaluate our staff or providers, improve the quality of care, conduct financial or billing audits, participate in insurance, defend legal matters, conduct business planning, store your records or contact you by telephone, email, or text to remind you of your appointments.

Disclosures Unless You Object: Unless you instruct us not to, we may release health information about you to a friend, family member or other person involved in your care. For example, we may assume that if your spouse or friend is present during your evaluation, that we can disclose protected professional information to this person.

Other Uses and Disclosures: In some limited situations and if certain conditions are satisfied, we also may use and disclose your information without your permission. Not all of these situations will apply, and some may never occur. Examples of some of these uses or disclosures are:

  • when a state or federal law mandates that certain health information be reported for a specific purpose;
  • for public health purposes, such as contagious disease reporting, investigation or surveillance, and notices to and from the federal Food and Drug Administration regarding drugs or medical devices;
  • to governmental authorities about victims of suspected abuse, neglect or domestic violence;
  • for health oversight activities, such as for the licensing, for audits by Medicare or Medicaid, or for investigation of possible violations of healthcare laws;
  • for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
  • for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime, to report or provide information about a crime;
  • to a medical examiner to identify a dead person or to determine the cause of death, or to funeral directors to aid in burial, or to organizations that handle organ or tissue donations;
  • for health related research that has been approved by an Institutional Review Board or its equivalent;
  • to prevent a serious threat to health or safety;
  • for specialized government functions, such as for the protection of the president or high ranking government officials, for lawful national intelligence activities, for military purposes, or for the evaluation and health of members of the foreign service;
  • disclosures of de-identified information;
  • disclosures relating to worker’s compensation programs;
  • disclosures of a “limited data set” for research, public health, or healthcare operations;
  • incidental disclosures that are an unavoidable by-product of permitted uses or disclosures; or disclosures to “business associates” who perform healthcare operations for us and who agree to comply with privacy and security laws and regulations that apply to them.


We will not make any other uses or disclosures of your information unless you sign a written “authorization form.” The content of an “authorization form” is determined by federal law. Sometimes, we may initiate the authorization process if the use or disclosure is our idea. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign the authorization, you may revoke it at any time unless we have already acted in reliance upon it. Your revocation of authorization must be in writing and sent to the contact person at the bottom of this Notice.

Sometimes, you may initiate the process if it is your idea for us to send your information to someone else. Typically, in this situation you will complete an authorization form.


We may contact you by phone (including leaving voicemail messages), write, e-mail or text message (including push notifications) (“communicate”) to remind you of scheduled appointments or the need to make a routine appointment. We also may communicate with you regarding other treatments or services available that may be of interest to you. In addition, we may communicate to follow up, conduct quality assessments, ask for feedback or similar activities. You understand that if we contact you to seek authorization for marketing, and if you decline to provide such consent, this will not affect your treatment. The Practice records video of consultations for training and care purposes unless patient requests otherwise.

If you e-mail us medical or billing information from a private email address (such as yahoo, gmail, etc.) your information will not be encrypted unless you use a secure messaging portal. If you request us to post your information in drop boxes, flash drives, or any type of share file, your information may not be secure. We are not responsible if your PHI is requested to be sent in an unsecure manner. We are also not responsible if your PHI is re-disclosed, damaged, altered or otherwise misused by a recipient. Additionally, if you share your e-mail account with someone else or print, post, or otherwise share your PHI it may not be private or secure.


The law gives you many rights regarding your health information. You can request any of the following rights by sending a written request to the contact at the bottom of this Notice.

Access to Health Information: You have the right to access and receive copies of your health information that we use to make decisions about your care. Generally, except in a few limited situations, you will be able to review or have a copy of your health information within 30 days of asking us. You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation. By law, we can have one 30 day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If we have information about you in electronic form, we will provide it to you electronically if we can agree with you about the format, such as PDF. If you wish, you can request that electronic health information that we have about you be sent to someone else that you specify. We will send the electronic information where you request so long as your instructions are clear and there is no other reason why we need to deny your request. You may have to pay for the cost of producing an electronic copy of your health information.

Amendment: If you believe your health information we have is incorrect or incomplete, you may ask us to amend the information. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30 day extension of time to consider a request for amendment if we notify you in writing of the extension.

Accounting of Disclosures: You have the right to receive a list of instances in which we disclosed your health information within the last 6 years (or shorter period if you want). This list will not include uses or disclosures: for treatment, payment, healthcare operations; that was pursuant to a valid authorization; incidental uses or disclosures; disclosures required by law; and some other limited disclosures. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30 day extension of time if we notify you of the extension in writing.

Restrictions to Health Information: You have to ask us to restrict or limit uses and disclosures for purposes of treatment (except emergency treatment), payment and healthcare operations. Except as described in the next sentence, we do not have to agree to do this, but if we agree, we must honor the restrictions that you want. We are required by law to agree to a request to restrict disclosure of your health information to a health plan if the disclosure is for payment or healthcare operations and pertains to a health care item or service for which you paid in full, out-of-pocket.

Confidential Communications: You have the right to ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home or only on your cell phone, by mailing health information to a different address, by using e-mail to your personal e-mail address or by not using e-mail or text message to communicate with you. We will accommodate these requests if they are reasonable and if you pay us for any extra cost.

Breach Notification: You may be notified in accordance with law if there is ever a data breach that involves your health information.

Copies of this Notice: You may request a hard copy of this Notice upon request. COMPLAINTS & INFORMATION

If you believe your privacy rights have been violated, you may file a complaint with us at the contact below. You may also file a complaint with the U.S. Department of Health and Human Services, Office of Civil Rights at (800) 368-1019, TDD toll-free: (800) 537-7697, or by emailing We will not retaliate against you if you make a complaint.

For more information regarding this Notice or our privacy practices you may contact us at 32241 Crown Valley Parkway, Suite 220, Dana Point, CA 92629, +1 (888) 209-5091, or