Privacy Statement

Regulatory Compliance

Sample Notice of Privacy Practices

A covered entity had until September 23, 2013, to update its notice of privacy practices with the 2013 HIPAA amendments. An article on the CDA Practice Support website, “HITECH Act Revises Certain HIPAA Provisions,” summarizes the amendments. This sample notice includes the required revisions.

This resource is provided by CDA for informational purposes only and should not be considered legal advice. Appropriate legal advice regarding a particular question or specific situation should be obtained by you from qualified legal counsel.

A covered entity is required to provide patients with its notice of privacy practices. The notice must include descriptions and a few examples of the types of uses and disclosures of protected health information that the covered entity is permitted to make without the individual’s written authorization, including for each of the following purposes: treatment, payment and health care operations. It should include a statement about the other uses and disclosures that the practice may use protected health information only with the individual’s written authorization. A statement on the individual’s rights with respect to the information and a brief description of how those rights may be exercised must be included in the notice. A covered entity must review its duties and obligations with respect to the protected health information, describe procedures for taking individual’s complaints and provide an effective date of the notice.

Instructions for the Dental Practice

Fill in the effective date on the first page of the notice and the contact information on the last page. Fill in the name of the dental practice at the top of the “Acknowledgement of Receipt of Notice of Privacy Practices.”

Provide the notice to a patient at the first encounter or soon after and obtain patient acknowledgement of receipt. Retain the acknowledgement with the patient record. The notice also must be posted where a patient is likely to view it and it must be made available upon request. Include the notice on the practice website.

When the notice is revised, notify patients of the revision and where they can obtain or view a copy. The notification can be posted in the office and included in patient mailings and the practice Web site. It is not necessary to distribute the new notice to current patients or to obtain an acknowledgement of receipt.

Dental practices that receive payments from certain types of government programs, such as Denti-Cal, Healthy Families, Medicare Advantage (Part C) or electronic health records incentive (“meaningful use”), must comply with the nondiscrimination requirements of the Affordable Care Act Section 1557. A notification statement and language taglines are included as part of this resources. If your dental practice is not required to comply with this rule, you need not include the taglines.

Notice of Privacy Practices

This notice describes how your health information may be used and disclosed and how you can get access to this information. Please review it carefully. The privacy of your health information is important to us.

Our Legal Duty

Federal and state laws require us to maintain the privacy of your health information. We are also required to provide this notice about our office’s privacy practices, our legal duties and your rights regarding your health information. We are required to follow the practices that are outlined in this notice while it is in effect. This notice takes effect December 8, 2022, and will remain in effect until we replace it.

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. We reserve the right to make changes in our privacy practices and the new terms of our notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this notice and make the new notice available upon request. For more information about our privacy practices or additional copies of this notice, please contact us (contact information below).

Uses and Disclosures of Health Information

We use and disclose health information about you for treatment, payment and health care operations.

For example:

Treatment

We disclose medical information to our employees and others who are involved in providing the care you need. We may use or disclose your health information to another dentist or other health care providers providing treatment that we do not provide. We may also share your health information with a pharmacist in order to provide you with a prescription or with a laboratory that performs tests or fabricates dental prostheses or orthodontic appliances.

Payment

We may use and disclose your health information to obtain payment for services we provide to you, 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.

Health Care Operations

We may use and disclose your health information in connection with our health care operations. Health care operations include, but are not limited to, quality assessment and improvement activities, reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization

In addition to our use of your health information for treatment, payment or health care operations, 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.

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.

Unsecured Email

We will not send you unsecured emails pertaining to your health information without your prior authorization. If you do authorize communications via unsecured email, you have the right to revoke the authorization at any time.

Persons Involved in Care

We may use or disclose 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 your 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 health care. 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, medical 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 plan, we may receive payment for communications to you in relation to our provision, coordination or management of your dental care, including our coordination or management of your health care 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 whether we receive payments for marketing activity you have authorized.

Change of Ownership

If this dental practice is sold or merged with another practice or organization, your health records will become the property of the new owner. However, you may request that copies of your health information be transferred to another dental practice.

Required by Law

We may use or disclose your health information when we are required to do so by law.

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. Upon reporting suspected elder or dependent adult abuse or domestic violence, we will promptly inform you or your personal representative unless we believe the notification would place you at risk of harm or would require informing a personal representative we believe is responsible for the abuse or harm.

Abuse or Neglect

We may disclose your health information to 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 to military authorities the health information of Armed Forces personnel under certain circumstances. 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.

Appointment Reminders

We may contact you to provide you with appointment reminders via 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 medical 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.

Patient Rights

Access

You have the right to look at or get copies of your 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 obtain a form to request access by contacting our office. 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 a charge for time spent. 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. Contact us 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, health care 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.

Restriction

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 these additional restrictions, but if we do, we will abide by our agreement (except in emergency). In the event 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.

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 satisfactory explanation of how payments will be handled under the alternative means or location you request.

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.

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.

Patient Rights

Questions and Complaints

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

Contact: Dr. Christina Gasper

Telephone: 415-986-4664

Fax: 415-986-1798

Email:  [email protected]

Address: 450 Sutter Street, Suite 2336, SF 94108

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may send a written complaint to our office or to the U.S. Department of Health and Human Services, Office of Civil Rights. We will not retaliate against you for filing a complaint.

Periodontal Dental Practice of Dr. Christina Gasper complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.

California

Persian (Farsi):

مرکز خدمات دندان‌پزشکی ما خدمات کمک زبانی را به صورت رایگان برای افرادی فراهم می‌آورد که انگلیسی را با تسلط صحبت نمی‌کنند تا در مورد مراقبت های دندانی که ارائه می‌کنیم گفتگو کنند.

Russian:

Наша стоматологическая клиника бесплатно предоставляет клиентам, которые не достаточно хорошо говорят на английском языке, услуги переводчика, чтобы помочь им обсудить предоставляемую нами стоматологическую помощь.

Japanese:

当社の歯科治療では提供している歯科ケアに関して話し合える程度の英語力のない方に無料で言語サポートサービスを提供していま。

Arabic:

سوف تقدم عيادة طب الأسنان مساعدة لغوية مجانية لأولئك الذين لا يجيدون الإنكليزية من أجل مناقشة خدمات العناية بالأسنان التي نقدمها.

Punjabi:

ਉਰ ਡੈਂਟਲ ਪ੍ਰੈਕਟਿਸ ਵਿਲ ਪ੍ਰੋਵੀਦੇ ਲੈਂਗੂਏਜ ਅੱਸੀਸਟੈਂਸ ਸਰਵਿਸਜ਼ ਫ੍ਰੀ-ਓਫ-ਚਾਰਜ ਤੋਂ ਇੰਡਿਵਿਦੁਲਸ ਹੂ ਦੋ ਨ ਸਪੈੱਕ ਇੰਗਲਿਸ਼ ਵੈੱਲ ਏਨੌਘ ਤੋਂ ਡਿਸਕਸ ਥੇ ਡੈਂਟਲ ਚਾਰੇ ਵੀ ਰੇ ਪ੍ਰੋਵੀਡੀਨਗ.

Mon-Khmer:

គ្លីនិកធ្មេញយើងខ្ញុំនឹងផ្ដល់នូវសេវាជំនួយផ្នែកភាសាដោយឥតគិតថ្លៃជូនដល់អតិថិជនម្នាក់ៗដែលមិនចេះនិយាយភាសាអង់ច្បាស់លាស់ ដើម្បីពិគ្រោះពិភាក្សាគ្នាអំពីបញ្ហាសេវាតំហែទាំធ្មេញដែលយើងខ្ញុំកំពុងផ្ដល់ជូន។

Hmong:

Ang aming pagsasanay ukol sa ngipin o dental practice ay magbibigay ng libreng mga serbisyong tulong sa mga indibiduwal na hindi masyadong nakakapagsalita ng Ingles upang talakayin ang pangangalaga sa ngipin na aming ibinibigay.

Hindi:

हमारे दंत चिकिच्छालय के प्रभारी, जो व्यक्ती अच्छी तरह ईंग्लीश बोल नही सकते है उनको, हम जो दंत चिकिच्छा देखभाल प्रदान कर रहे है उसके बारेमें बात करनेके लिये बीना कोई फ़ीस भाषा सहायता सेवाएं प्रदान करेंगे |

Thai:

แนวปฏิบัติด้านทันตกรรมของเราจะให้บริการช่วยเหลือด้านภาษาฟรีแก่บุคคลที่พูดภาษาอังกฤษไม่ชำนาญเพียงพอที่จะหารือเกี่ยวกับบริการทันตกรรมของเรา