1094 W 7th St, San Pedro, CA 90731

Shoreside Dental

Notice of Privacy Practices

THIS 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.

I. Dental Practice Covered by this Notice

This Notice describes the privacy practices of Shoreside Dental (“Dental Practice”). “We” and “our” means the Dental Practice. “You” and “your” means our patient.II. How to Contact Us/Our Privacy OfficialIf you have any questions or would like further information about this Notice, you can contact Shoreside Dental’s Privacy Official

III. Our Promise to You and Our Legal ObligationsThe privacy of your health information is important to us. We understand that your health information is personal and we are committed to protecting it. This Notice describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected health information is information about you, includingdemographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

We are required by law to:

• Maintain the privacy of your protected health information;• Give you this Notice of our legal duties and privacy practices with respect to thatinformation; and• Abide by the terms of our Notice that is currently in effect.

IV. Last Revision Date

This Notice was last revised on April 15, 2018.

V. How We May Use or Disclose Your Health InformationThe following examples describe different ways we may use or disclose your healthinformation. These examples are not meant to be exhaustive. We are permitted by lawto use and disclose your health information for the following purposes:Printed copies of this document are considered uncontrolled.18898.1.Rev002 04.15.2018

A. Common Uses and Disclosures

1. Treatment. We may use your health information to provide you with dental treatmentor services, such as cleaning or examining your teeth or performing dental procedures.We may disclose health information about you to dental specialists, physicians, or otherhealth care professionals involved in your care.

2. Payment. We may use and disclose your health information to obtain payment fromhealth plans and insurers for the care that we provide to you.

3. Health Care Operations. We may use and disclose health information about you inconnection with health care operations necessary to run our practice, including reviewof our treatment and services, training, evaluating the performance of our staff andhealth care professionals, quality assurance, financial or billing audits, legal matters,and business planning and development.

4. Appointment Reminders. We may use or disclose your health information whencontacting you to remind you of a dental appointment. We may contact you by using apostcard, letter, phone call, voice message, text or email.

5. Treatment Alternatives and Health-Related Benefits and Services. We may useand disclose your health information to tell you about treatment options or alternativesor health-related benefits and services that may be of interest to you.

6. Disclosure to Family Members and Friends. We may disclose your healthinformation to a family member or friend who is involved with your care or payment foryour care if you do not object or, if you are not present, we believe it is in your bestinterest to do so.

7. Disclosure to Business Associates. We may disclose your protected healthinformation to our third-party service providers (called, “business associates”) thatperform functions on our behalf or provide us with services if the information isnecessary for such functions or services. For example, we may use a businessassociate to assist us in maintaining our practice management software. All of ourbusiness associates are obligated, under contract with us, to protect the privacy of yourinformation and are not allowed to use or disclose any information other than asspecified in our contract.

B. Less Common Uses and Disclosures

1. Disclosures Required by Law. We may use or disclose patient health information tothe extent we are required by law to do so. For example, we are required to disclosepatient health information to the U.S. Department of Health and Human Services so thatit can investigate complaints or determine our compliance with HIPAA.

2. Public Health Activities. We may disclose patient health information for publichealth activities and purposes, which include: preventing or controlling disease, injury ordisability; reporting births or deaths; reporting child abuse or neglect; reporting adversereactions to medications or foods; reporting product defects; enabling product recalls;and notifying a person who may have been exposed to a disease or may be at risk forcontracting or spreading a disease or condition.Printed copies of this document are considered uncontrolled.18898.1.Rev002 04.15.2018

3. Victims of Abuse, Neglect or Domestic Violence. We may disclose healthinformation to the appropriate government authority about a patient whom we believe isa victim of abuse, neglect or domestic violence.

4. Health Oversight Activities. We may disclose patient health information to a healthoversight agency for activities necessary for the government to provide appropriateoversight of the health care system, certain government benefit programs, andcompliance with certain civil rights laws.

5. Lawsuits and Legal Actions. We may disclose patient health information inresponse to (i) a court or administrative order or (ii) a subpoena, discovery request, orother lawful process that is not ordered by a court if efforts have been made to notify thepatient or to obtain an order protecting the information requested.

6. Law Enforcement Purposes. We may disclose your health information to a lawenforcement official for a law enforcement purposes, such as to identify or locate asuspect, material witness or missing person or to alert law enforcement of a crime.

7. Coroners, Medical Examiners and Funeral Directors. We may disclose yourhealth information to a coroner, medical examiner or funeral director to allow them tocarry out their duties.

8. Organ, Eye and Tissue Donation. We may use or disclose your health informationto organ procurement organizations or others that obtain, bank or transplant cadavericorgans, eyes or tissue for donation and transplant.

9. Research Purposes. We may use or disclose your information for researchpurposes pursuant to patient authorization waiver approval by an Institutional ReviewBoard or Privacy Board.

10. Serious Threat to Health or Safety. We may use or disclose your healthinformation if we believe it is necessary to do so to prevent or lessen a serious threat toanyone’s health or safety.

11. Specialized Government Functions. We may disclose your health information tothe military (domestic or foreign) about its members or veterans, for national securityand protective services for the President or other heads of state, to the government forsecurity clearance reviews, and to a jail or prison about its inmates.

12. Workers’ Compensation. We may disclose your health information to comply withworkers’ compensation laws or similar programs that provide benefits for work-relatedinjuries or illness.

VI. Your Written Authorization for Any Other Use or Disclosure of Your HealthInformation

Uses and disclosures of your protected health information that involve the release ofpsychotherapy notes (if any), marketing, sale of your protected health information, orother uses or disclosures not described in this notice will be made only with your writtenauthorization, unless otherwise permitted or required by law. You may revoke thisauthorization at any time, in writing, except to the extent that this office has taken anaction in reliance on the use of disclosure indicated in the authorization. If a use ordisclosure of protected health information described above in this notice is prohibited orPrinted copies of this document are considered uncontrolled.18898.1.Rev002 04.15.2018

materially limited by other laws that apply to use, we intend to meet the requirements ofthe more stringent law.

VII. Your Rights with Respect to Your Health Information

You have the following rights with respect to certain health information that we haveabout you (information in a Designated Record Set as defined by HIPAA). To exerciseany of these rights, you must submit a written request to our Privacy Official listed onthe first page of this Notice.

A. Right to Access and Review

You may request to access and review a copy of your health information. We may denyyour request under certain circumstances. You will receive written notice of a denial andcan appeal it. We will provide a copy of your health information in a format you requestif it is readily producible. If not readily producible, we will provide it in a hard copy formator other format that is mutually agreeable. If your health information is included in anElectronic Health Record, you have the right to obtain a copy of it in an electronic formatand to direct us to send it to the person or entity you designate in an electronic format.We may charge a reasonable fee to cover our cost to provide you with copies of yourhealth information.

B. Right to Amend

If you believe that your health information is incorrect or incomplete, you may requestthat we amend it. We may deny your request under certain circumstances. You willreceive written notice of a denial and can file a statement of disagreement that will beincluded with your health information that you believe is incorrect or incomplete.

C. Right to Restrict Use and Disclosure

You may request that we restrict uses of your health information to carry out treatment,payment, or health care operations or to your family member or friend involved in yourcare or the payment for your care. We may not (and are not required to) agree to yourrequested restrictions, with one exception: If you pay out of your pocket in full for aservice you receive from us and you request that we not submit the claim for thisservice to your health insurer or health plan for reimbursement, we must honor thatrequest.

D. Right to Confidential Communications, Alternative Means and Locations

You may request to receive communications of health information by alternative meansor at an alternative location. We will accommodate a request if it is reasonable and youindicate that communication by regular means could endanger you. When you submit awritten request to the Privacy Official listed on the first page of this Notice, you need toprovide an alternative method of contact or alternative address and indicate howpayment for services will be handled.

E. Right to an Accounting of Disclosures

You have a right to receive an accounting of disclosures of your health information forthe six (6) years prior to the date that the accounting is requested except for disclosuresto carry out treatment, payment, health care operations (and certain other exceptions asPrinted copies of this document are considered uncontrolled.18898.1.Rev002 04.15.2018

provided by HIPAA). The first accounting we provide in any 12-month period will bewithout charge to you. We may charge a reasonable fee to cover the cost for eachsubsequent request for an accounting within the same 12-month period. We will notifyyou in advance of this fee and you may choose to modify or withdraw your request atthat time.

F. Right to a Paper Copy of this Notice

You have the right to a paper copy of this Notice. You may ask us to give you a papercopy of the Notice at any time (even if you have agreed to receive the Noticeelectronically). To obtain a paper copy, ask the Privacy Official.

G. Right to Receive Notification of a Security Breach

We are required by law to notify you if the privacy or security of your health informationhas been breached. The notification will occur by first class mail within sixty (60) days ofthe event. A breach occurs when there has been an unauthorized use or disclosureunder HIPAA that compromises the privacy or security of your health information.

The breach notification will contain the following information:

(1) a brief description ofwhat happened, including the date of the breach and the date of the discovery of thebreach;
(2) the steps you should take to protect yourself from potential harm resultingfrom the breach; and
(3) a brief description of what we are doing to investigate thebreach, mitigate losses, and to protect against further breaches.

VIII. Special Protections for HIV, Alcohol and Substance Abuse, Mental Health andGenetic Information

Certain federal and state laws may require special privacy protections that restrict theuse and disclosure of certain health information, including HIV-related information,alcohol and substance abuse information, mental health information, and geneticinformation. For example, a health plan is not permitted to use or disclose geneticinformation for underwriting purposes. Some parts of this HIPAA Notice of PrivacyPractices may not apply to these types of information. If your treatment involves thisinformation, you may contact our office for more information about these protections.

IX. Our Right to Change Our Privacy Practices and This Notice

We reserve the right to change the terms of this Notice at any time. Any change willapply to the health information we have about you or create or receive in the future. Wewill promptly revise the Notice when there is a material change to the uses ordisclosures, individual’s rights, our legal duties, or other privacy practices discussed inthis Notice. We will post the revised Notice on our website (if applicable) and in ouroffice and will provide a copy of it to you on request. The effective date of this Notice is04/15/2018.

X. How to Make Privacy Complaints

If you have any complaints about your privacy rights or how your health information hasbeen used or disclosed, you may file a complaint with us by contacting our PrivacyOfficial listed on the first page of this Notice.Printed copies of this document are considered uncontrolled.18898.1.Rev002 04.15.2018

You may also file a written complaint with the Secretary of the U.S. Department ofHealth and Human Services, Office for Civil Rights. We will not retaliate against you inany way if you choose to file a complaint.