Federal and state laws require us to maintain the privacy and security of your protected health information. We are also required to provide this Notice about our Dental Practice’s privacy practices, our legal duties, and your rights regarding your health information. We must follow the duties and privacy practices that are described in this Notice while it is in effect and give you a copy of it. This Notice takes effect on 03/25/2014 and will remain in effect until we replace it. We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time by informing us, using the contact information below.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request. New terms of our Notice will be effective for all health information that we maintain, including health information we created or received before we made the changes.

We typically use or share information in the following ways:

Treatment:

We may use your health information and share it with our employees and other professionals who are treating you. We may use or disclose your health information to another health care provider. Examples include: sharing your Dental information with a doctor treating you who asks your former doctor about your previous treatments, with a laboratory that performs tests or fabricates prostheses or orthodontic appliances, with a pharmacist to provide you with a prescription, or with a Dental Practice specialist to provide you with services not offered by our practice.

Payment:

We may use and share your health information to bill and receive payment from health plans or other entities unless you request that we restrict such disclosure to your health plan when you have paid out-of-pocket and in full for services rendered.

Healthcare Operations:

We may use and disclose your health information about our healthcare operations. Healthcare operations include activities related to running our practice, improving your care, and contacting you, when necessary. Healthcare operations also include using health information about you to manage your treatment and services. Some examples include, but are not limited to, engaging in quality assessment and improvement activities; reviewing the competence or qualifications of healthcare professionals; evaluating practitioner and provider performance; conducting training programs, accreditation, certification, licensing or credentialing activities.

Public Health:

We may, and are sometimes legally obligated to, disclose your health information to public health agencies for purposes related to preventing or controlling disease, injury, or disability; reporting abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure.

Abuse or Neglect:

We may disclose your health information to the appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security:

We may disclose health information about you for specialized government functions such as military, national security, and presidential protective services. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institutions or law enforcement officials having lawful custody of protected health information of inmates or patients under certain circumstances.

To Comply with the Law:

We will share information about you if a state or federal law requires it. This includes disclosures to courts upon a court order, to law enforcement with search warrants, or to other government entities with orders pursuant to their respective legal authority and the U.S. Department of Health and Human Services if it wants to see that we are complying with federal privacy law.

Appointment Reminders:

We may contact you to provide you with appointment reminders via email, text messages, voicemail, postcards, or letters. We may also leave a message with the person answering the phone if you are not available.

Sign-In Sheet and Announcement:

Upon arriving at our office, we may use and disclose Dental information about you by asking that you sign an intake sheet at our front desk. We may also announce your name when we are ready to see you.

To Your Family and Friends:

We must disclose your health information to you, as described in the Patient Rights section of this Notice. You have the right to request restrictions on disclosure to family members, other relatives, close personal friends, or any other person identified by you.

Persons Involved in Care:

We may use or disclose your health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, Dental supplies, X-rays, or other similar forms of health information.

Marketing Health-Related Services:

We may contact you about products or services related to your treatment, case management or care coordination, or to propose other treatments or health-related benefits and services in which you may be interested. We may also encourage you to purchase a product or service when you visit our office. If you are currently an enrollee of a Dental Practice office plan, we may receive payment for communications to you in relation to our provision, coordination, or management of your Dental Practice office care, including our coordination or management of your healthcare with a third party, our consultation with other health care providers relating to your care, or if we refer you for health care. We will not otherwise use or disclose your health information for marketing purposes without your written authorization. We will disclose to you whether we receive payments for marketing activities that you have authorized.

Research:

Your health information may be disclosed to researchers for research purposes. In this situation written authorization is not required as approved by an Institutional Review Board or privacy board.

Other Uses and Disclosures of Your Health Information:

Your authorization is required, with a few exceptions, for disclosure of psychotherapy notes, use or disclosure of your health information for marketing, and for the sale of your PHI. We will also obtain your written authorization before using or disclosing your health information for purposes other than those provided for in this Notice (or as otherwise permitted or required by law). You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your health information, except to the extent that we have already taken action in reliance on the authorization.

Your Authorization:

In addition to our use of your health information for treatment, payment, or healthcare operations and otherwise as described in this Notice, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it is in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

Access:

You have the right to see or obtain electronic or paper copies of your Dental record and other health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. You may contact our office to obtain a form to request access. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter. If you request copies, there may be an additional cost-based fee. If you request an alternate format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. You may contact our office to request a copy of your Dental record or for a full explanation of our fee structure.

Disclosure Accounting:

You have a right to receive a list of instances in which we disclosed your health information for purposes other than treatment, payment, healthcare operations and certain other activities for the last six years. If you request this accounting more than once in a 12-month period, we may charge you a reasonable cost-based fee for responding to these additional requests. You may contact our office to request a disclosure accounting.

Additional Restrictions:

You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to additional restrictions, but if we do, we will abide by our agreement (except in an emergency).For example, if you pay out-of-pocket and in full for services rendered, you may request that we not share your health information with your health plan. We must agree to this request. You may contact our office to request additional restrictions.

Alternative Communication:

You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. You must make your request in writing. Your request must specify the alternative means or location and provide a satisfactory explanation of how payments will be handled under the alternative means or location you request. You may contact our office to obtain a form to request alternative communication. See Patient Disclosure Instructions form – (PDI form).

Amendment:

You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended). We may deny your request under certain circumstances. You may contact our office to obtain a form to request an amendment.

Breach Notification:

In the event your unsecured protected health information is breached, we will notify you as required by law. In some situations, you may be notified by our business associates.

Questions and Complaints:

If you want more information about our privacy practices or have questions or concerns, please contact our Privacy Official at:

Contact Name: Dr. Negari
Address: 14495 South Bascom Ave, Los Gatos , CA 95032

If you are concerned that we may have violated your privacy rights, you may send a written complaint to our office. You can also file a complaint with the U.S. Department of Health and Human Services. We will not retaliate against you for filing a complaint. This Dental Practice will never condition the provision of treatment or payment on obtaining a waiver from an individual on his or her right to file complaints under this section.