This notice is required by law to tell you how our practice protects the confidentiality of your health care information in our possession. Protected Health Information (PHI) is defined as any individually identifiable information regarding a patient’s health care history; mental or physical condition; or treatment. Some examples of PHI include your name, address, telephone and/or fax number, electronic mail address, social security number or other identification number, date of birth, date of treatment, treatment records, x-rays, enrollment and claims records. Our practice receives, uses and discloses your PHI to administer your benefit plan or as permitted or required by law. Any other disclosure of your PHI without your authorization is prohibited.

We must follow the privacy practices that are described in this notice, but also comply with any stricter requirements under federal or state law that may apply to our administration of your benefits. However, we may change this notice and make the new notice effective for all of your PHI that we maintain. If we make any substantive changes to our privacy practices, we will promptly change this notice and redistribute to you within 60 days of the change to our practices. You may also request a copy of this notice anytime by contacting the address or phone number at the end of this notice. You should receive a copy of this notice at the time of your first appointment, and we will notify you of how you can receive a copy of this notice every three years. Please review this document carefully and ask for clarification if you do not understand any portion of it.


Our Practice is required by law to maintain the privacy of your protected health information and provide you with certain rights with regard to your protected health information. It is obligated to provide you with a copy of this Notice setting forth the Agency’s legal duties and its privacy practices with respect to your protected health information. Our Practice and any of its business associate must abide by the terms of this Notice.


Your protected health information may be used and disclosed where it is necessary for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of your physician’s practice.

Business AssociatesWe contract with service providers – called business associates – to perform various functions on its behalf. For example, we may contract with a service provider to perform the administrative functions necessary to pay your dental claims. To perform these functions or to provide the services, business associates will receive, create, maintain, transmit, use, or disclose protected health information, but only after our practice and the business associate agree in writing to contract terms requiring the business associate to appropriately safeguard your information.


We may use or disclose personal health information in order to provide, coordinate, or manage your health care and related services. This includes sharing your health information with other health care providers, both within and outside this agency, regarding your treatment when we need to coordinate and manage your health care. For example, we may share your health information with doctors, nurses and other health care personnel who are involved in providing your health care. Sharing health information can be essential for your protection and quality care.

Payment for Services

We may use and give your health information to other staff and health plans you designate to bill and collect payment for the health care services received by you. We may share information with your health plan to determine coverage status prior to scheduled services. We will share adequate information with departments that prepare bills and manage client accounts in order to ensure payment for services rendered. We may share your health information with agents of your insurance company or health plan to confirm services that were provided to you.

Health Care Operations

We may use or disclose, as needed, your protected health information in order to support the business activities of our practice. These “health care operations” allow us to improve the quality of care we provide to you and our other clients and help us to reduce health care costs. Such activities include, but are not limited to, quality assessment activities, employee review activities, training of dental students, licensing, and conducting or arranging for other business activities.

We may also use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you.

We may use or disclose your demographic information and the dates that you received treatment from your physician, as necessary, in order to contact you for fundraising activities supported by our office. If you do not wish to receive materials of this nature, please contact our staff and request that these fundraising materials not be sent to you.


We are required to disclose your PHI to you or your authorized personal representative (with certain exceptions), when required by the U. S. Secretary of Health and Human Services Office for Civil Rights to investigate or determine our compliance with law, and when otherwise required by law. We may disclose your PHI without your prior authorization in response to the following:

  • Court order;
  • Order of a board, commission, or administrative agency for purposes of adjudication pursuant to its lawful authority;
  • Subpoena in a civil action;
  • Investigative subpoena of a government board, commission, or agency;
  • Subpoena in an arbitration;
  • Law enforcement search warrant; or
  • Coroner’s request during investigations


Right to Inspect and Copy Your Protected Health Information. You have the right to inspect and copy protected health information that may be used to make decisions about your benefits. You must submit your request in writing. For your convenience, you may request a form using the Contact Information at the end of this Notice. Such requests will be fulfilled within 30 days where possible. If you request copies, we may impose reasonable copy charges (which may include a labor charge), as well as postage if you request copies be mailed to you.

You may also request that we disclose your protected health information to an individual who has been designated by you as your personal representative and who has qualified for such designation in accordance with relevant law. Prior to such a disclosure, however, we must be given written documentation that supports and establishes the basis for the personal representation.

Note that under federal law, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some, but not all, circumstances, you may have a right to have this decision reviewed.

Right to Request a Restriction. You have the right to request that Our Practice restrict use or disclosure of protected health information for treatment, payment or health care operations, disclosure to persons involved in the individual’s health care or payment for health care, or disclosure to notify family members or others about the individual’s general condition, location, or death. We are under no obligation to agree to requests for restrictions. In circumstances in which we do agree to a restriction, we will comply with the agreed restrictions, except for purposes of treating you in a medical emergency.

Right to Non-Disclosure to Health Plan. A patient that pays in full for their services out of pocket have the right to demand that the information regarding the service not be disclosed to the patient’s third party payer since no claim is being made against the third party payer.

Right to Request Confidential Communications. You have the right to request an alternative means or location for receiving communications of protected health information by means other than those that Our Practice typically employs. For example, you may request that we communicate with you through a designated address or phone number. Similarly, you may request that we send communications in a closed envelope rather than a post card.

We will also accommodate reasonable requests if you indicate that the disclosure of all or part of the protected health information could endanger you. We will not question your statement of endangerment. Any confidential communication request must be done in writing and must explain how any payment will be handled.

Right to Request an Amendment. HIPAA gives individuals the right to have covered entities amend their protected health information in a designated record set when that information is inaccurate or incomplete. If we accept an amendment request, we will make reasonable efforts to provide the amendment to persons that you identify as needing it and to persons that we know might rely on the information to your detriment. If the request is denied, we will provide you with a written denial and allow you to submit a statement of disagreement for inclusion in the record. Furthermore we will amend protected health information in our designated record set upon receipt of notice to amend from another covered entity.

Right to Request an Accounting. You have a right to an accounting of the disclosures of your protected health information by our practice or any business associates with whom we do business. The maximum disclosure accounting period is the six years immediately preceding the accounting request, except we are not obligated to account for any disclosure made before our Privacy Rule compliance date.

The Privacy Rule does not require accounting for disclosures:

  • for treatment, payment, or health care operations;
  • to the individual or the individual’s personal representative;
  • for notification of or to persons involved in an individual’s health care or payment for health care,
  • for disaster relief, or for facility directories;
  • pursuant to an authorization;
  • of a limited data set;
  • for national security or intelligence purposes;
  • to correctional institutions or law enforcement officials for certain purposes regarding inmates or individuals in lawful custody; or
  • incident to otherwise permitted or required uses or disclosures.
  • accounting for disclosures to health oversight agencies and law enforcement officials must be temporarily suspended on their written representation that an accounting would likely impede their activities.

Right to Opt out of Fundraising Communications. You have the right to opt out of any fundraising communications that eminent from our practice or any business associates with whom we do business. Treatment or payments are not conditioned upon whether or not you choose to receive or opt out of such communications. If at any time you wish to opt back in to fundraising communication, you may do so. To elect or change your fundraising communication preferences, please contact the appropriate person using the Contact Information on this Notice.

Right to be Notified of a Breach. You have the right to be notified in the event that our practice or any business associates with whom we do business discovers a breach of unsecured protected health information.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice, even if you have agreed to accept this Notice electronically. To obtain such a copy, please contact the appropriate person using the Contact Information on this Notice.


You may complain to us or to the U. S. Secretary of Health and Human Services or State Attorney General if you believe that our practice has violated your privacy rights. You may file a complaint with us by notifying the privacy officer as noted below. We will not retaliate against you for filing a complaint.


You may contact the Privacy Officer at the address and telephone number listed below for further information about the complaint process or any of the information contained in this notice.

Novato Family Dental Care
7460 Redwood Blvd.
Novato, CA 94945
T: (415) 897-3914

This Notice of Privacy Practices is effective 3/18/15