Notice of Privacy Practices
Maz Endodontics · Dr. Maziyar Ebrahimi, DMD 9735 Wilshire Blvd, Suite 426, Beverly Hills, CA 90212 · (310) 248-3636
Effective date: [counsel to set upon approval]
Counsel note: this draft contains the content elements required by 45 CFR 164.520 written out in full, plus California CMIA considerations. It requires final review and sign-off by qualified HIPAA counsel before publication and before distribution to patients, and the practice must also: (1) name a Privacy Officer in Section 10, (2) post the approved Notice in the office and provide it at first service with written acknowledgment, and (3) confirm the state-law provisions in Section 8 against current California statute.
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.
1. Our Legal Duties
Maz Endodontics is required by law to maintain the privacy of your protected health information (“PHI”), to give you this Notice of our legal duties and privacy practices with respect to PHI, to follow the terms of the Notice currently in effect, and to notify you if a breach of your unsecured PHI occurs. PHI is information that identifies you and relates to your health, the care we provide, or payment for that care.
2. How We May Use and Disclose Your Health Information Without Your Authorization
For Treatment. We use your PHI to provide, coordinate, and manage your endodontic care. Examples: reviewing your health history before a procedure, taking and interpreting X-rays, and sharing findings and treatment records with your referring or general dentist so your overall care is coordinated.
For Payment. We use and disclose PHI to bill and collect payment. Examples: verifying your insurance eligibility, submitting claims to your dental plan with the diagnosis and procedures performed, and responding to your plan’s requests for records supporting a claim.
For Health Care Operations. We use PHI to run the practice. Examples: quality review of cases, training, licensing and accreditation activities, business planning, and customer service, including resolving complaints.
Appointment Reminders and Care Communications. We may contact you by phone, text, mail, or email to remind you of appointments, follow up after procedures, or tell you about treatment options. If you reach us by text, we may reply by text. Tell us if you prefer a different method or a specific number or address (see Your Rights below).
Individuals Involved in Your Care. We may share PHI relevant to their involvement with a family member, friend, or other person you identify as involved in your care or payment for it, and we may notify such a person of your location or condition. You may object to these disclosures.
As Required by Law. We disclose PHI when federal, state, or local law requires it.
Public Health. We may disclose PHI to public health authorities for purposes such as disease reporting and product-safety reporting, and to report suspected abuse or neglect as required or permitted by law.
Health Oversight. We may disclose PHI to agencies that oversee the health care system, such as the Dental Board of California, for audits, investigations, inspections, and licensure.
Judicial and Administrative Proceedings. We may disclose PHI in response to a court or administrative order, and in response to a subpoena or discovery request when legal requirements protecting your information are satisfied.
Law Enforcement. We may disclose limited PHI to law enforcement in defined circumstances, such as responding to a warrant or court order, identifying or locating a suspect or missing person, or reporting a crime on our premises.
Coroners, Medical Examiners, and Funeral Directors. We may disclose PHI as needed for them to carry out their duties, including identifying a deceased person.
Organ and Tissue Donation. We may disclose PHI to organizations that handle organ, eye, or tissue procurement or transplantation as permitted by law.
Research. We may use or disclose PHI for research when an authorized review board has approved the research and established protections for your information, or in other circumstances permitted by law.
To Avert a Serious Threat. We may use or disclose PHI when necessary to prevent a serious and imminent threat to the health or safety of you, another person, or the public, limited to persons able to help prevent the threat.
Specialized Government Functions. We may disclose PHI for military, national security, protective services, and correctional purposes as permitted by law.
Workers’ Compensation. We may disclose PHI as authorized by workers’ compensation laws for work-related injuries or illness.
Business Associates. Some services are provided through contractors, such as billing services or IT support. Our contracts require them to safeguard your PHI to the standards required by law.
3. Uses and Disclosures That Require Your Written Authorization
We will obtain your written authorization before:
- Marketing communications made in exchange for payment from a third party
- Sale of PHI (we do not sell PHI)
- Most disclosures of psychotherapy notes (rarely applicable in a dental setting, listed because the law requires it)
- Any other use or disclosure not described in this Notice
You may revoke an authorization at any time by writing to us, except to the extent we have already acted on it.
4. Your Rights Regarding Your Health Information
Right to Access and Copies. You may inspect and obtain a copy of your dental record, including X-rays, in the form you request if readily producible (including electronic copies of electronic records). We may charge a reasonable cost-based fee. California law generally entitles you to inspection within 5 business days and copies within 15 days of a written request.
Right to Amend. If you believe information in your record is incorrect or incomplete, you may request an amendment in writing, with a reason. We may deny the request in certain cases (for example, if we did not create the record), and if we deny it, you may submit a statement of disagreement that becomes part of your record.
Right to an Accounting of Disclosures. You may request a list of certain disclosures we made of your PHI in the six years before your request, excluding disclosures for treatment, payment, operations, and those you authorized. The first accounting in a 12-month period is free.
Right to Request Restrictions. You may ask us to limit how we use or disclose your PHI. We are not required to agree to most requested restrictions, but we must agree to one: if you pay for a service in full out of pocket and ask us not to disclose that service to your health plan, we will honor that request unless disclosure is required by law.
Right to Confidential Communications. You may ask us to contact you in a specific way or at a specific location, for example, only on your mobile number, or no voicemails. We will accommodate reasonable requests without asking why.
Right to a Paper Copy. You may request a paper copy of this Notice at any time, even if you agreed to receive it electronically. The current Notice is available at our office and on our website.
Right to Breach Notification. We will notify you in writing if a breach occurs that compromises the privacy or security of your unsecured PHI.
To exercise any of these rights, contact us using the information in Section 10. Requests for access, amendment, restriction, and accounting should be in writing.
5. Uses and Disclosures Requiring an Opportunity to Object
Before sharing information with family or friends involved in your care (Section 2), we will where practicable give you the chance to object. In an emergency or when you are not present, we will use professional judgment to determine whether disclosure is in your best interest and disclose only what is directly relevant.
6. Minimum Necessary
Except for treatment purposes and other exceptions permitted by law, we use and disclose only the minimum PHI necessary for the purpose.
7. Text and Email Communications
Standard text messages and email are convenient but not fully secure. If you initiate contact by text or email, we may reply the same way about the matter you raised. You may request at any time that we communicate only by more secure means, and we will accommodate reasonable requests.
8. California Law
California’s Confidentiality of Medical Information Act (CMIA) provides protections in addition to HIPAA. Where California law is more protective of your information than federal law, we follow California law. This includes stricter limits on certain disclosures and the record-access timelines described in Section 4. [Counsel: verify the CMIA-specific statements and access timelines against current statute before publication.]
9. Changes to This Notice
We reserve the right to change this Notice and to make the new terms effective for all PHI we maintain, including information created or received before the change. The current Notice is posted in our office and on our website, and you may request a copy at any time.
10. Questions, Requests, and Complaints
Privacy Officer: [name — practice to designate] Maz Endodontics, 9735 Wilshire Blvd, Suite 426, Beverly Hills, CA 90212 · (310) 248-3636
If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer at the address above, or with the Secretary of the U.S. Department of Health and Human Services, Office for Civil Rights. You will never be retaliated against for filing a complaint.