Periodontal Associates

Notice of Privacy Practices

Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and California privacy laws, we are required to maintain the privacy and security of your protected health information (PHI). We are also required to post in a clear and prominent location, and provide patients with this Notice of Privacy Practices, which details our privacy practices, our legal duties, and your rights concerning your PHI. This Notice is currently in effect 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 law. If changes are made, a new Notice of Privacy Practices will be displayed in our office and will be available on request. You may request a copy of our Notice at any time.

We will let you know promptly if a breach occurs that may have compromised the privacy and security of your PHI.

We will not use or share your information other than as described here unless you tell us we can in writing. You may change your mind at any time. Let us know in writing.

USES AND DISCLOSURES OF HEALTH INFORMATION

The following describes how PHI about you may be used in this dental office:

Treatment Services: We may use or disclose your PHI to a physician or other health care provider providing treatment to you.

Payment: We may use and disclose your PHI to obtain payment for services we provide to you. Upon your written request, we will not disclose to your health insurance company any services paid by you out of pocket.

Healthcare Operations: We may use and disclose your PHI in connection with our healthcare operations, which include quality assurance, disease management, training, licensing, and certification programs.

Other Authorizations: In addition to our use of your PHI for treatment, payment, or healthcare 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 was in effect. Unless you give us a written authorization, we cannot use or disclose your PHI for any reason except those described in this notice.

Family Members, Friends, and Others Involved in Care: Only if you agree that we may do so, we may disclose your PHI to a family member, friend, or other person if necessary to assist with your treatment and/or payment for services. We may also make information available so that another person may pick up filled prescriptions, medical supplies, records, or x-rays for you. If you are present, then prior to use or disclosure of your PHI, 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 PHI that is directly relevant to the person's involvement in your healthcare. Your PHI may be disclosed to assist in notifying a family member, caregiver, or personal representative of your location, condition, or death.

Marketing/Fundraising: We will not use your PHI for marketing or fundraising purposes without your written consent. You can opt out of receiving information about our marketing or fundraisers. We will not sell your PHI without your explicit authorization.

Appointment Reminders: We may use or disclose your PHI to provide you with appointment reminders such as voicemail messages, postcards, or letters. We will use unencrypted email for communicating with you at your specific request only.

Legal Requirements: We may disclose your PHI when required to do so by law.

Abuse or Neglect: If abuse, neglect, or domestic violence is reasonably suspected, we may use or disclose your PHI to the appropriate authorities to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: When required, we may disclose to military authorities the PHI of Armed Forces personnel. Information may be given to authorized federal officials when required for intelligence, counterintelligence, and national security activities. Under certain circumstances, we may disclose PHI of inmate(s) to correctional institutions or law enforcement officials having lawful custody of the inmate(s).

Business Associates: Some services in our organization are provided through contacts with business associates. Examples include practice management software representatives, accountants, answering service personnel, etc. When these services are contracted, we may disclose your PHI to our business associates so that they can perform the job we have asked them to do and bill you or your third-party payer for services rendered. All of our business associates are required to safeguard your PHI and to follow HIPAA Privacy Rules.

Public Health Activities: We may disclose medical information for public health activities, to include the following: to prevent or control disease, injury, or disability; to report reactions with medications or problems with products; to notify people of recalls of products they may be using; to notify a person who may have been exposed to a disease or who may be at risk for contracting or spreading a disease or condition.

Additional Restrictions on Use and Disclosure: Some laws may require special privacy protections that restrict the use and disclosure of certain types of PHI: alcohol and substance use disorders, biometric information, child or adult abuse or neglect including sexual assault, communicable diseases, genetic information, HIV/AIDS, mental health, prescriptions, reproductive health, and sexually transmitted diseases. We will follow the more stringent law, where it applies to us.

Substance Use Disorder (SUD) Information: Although we are not a SUD treatment program under federal law, we may receive information from a SUD Program about you. We may not disclose SUD information for use in a civil, criminal, administrative, or legislative proceeding against you unless we have (i) your written consent, or (ii) a court order accompanied by a subpoena or other legal requirement.

Breach Notification: We will notify you any time your PHI may have been compromised through unauthorized acquisition, access, use or disclosure.

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.

We will charge you a reasonable cost-based fee for expenses such as copies and staff time. If you request x-rays, there will be a fee for any copies of films. You are not entitled to originals, only copies. Postage will be added if copies are to be mailed. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Details of all fees are available from the HIPAA Coordinator.

Accounting of Disclosures: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, healthcare operations and certain other activities, for the last 6 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 will keep your information confidential from your health plans if you pay in cash, at your request. In some instances, we may not be required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

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 managed under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing and must explain the reason for the amendment.) We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our website or by email, you are entitled to receive this Notice in written form.

INFORMED CONSENT: VIDEO SURVEILLANCE FOR SECURITY PURPOSES

Purpose of video surveillance

• Periodontal Associates, Shayna Rondon DDS Inc, uses video surveillance for the security of our patients, staff, and property. Surveillance is used for quality assessments, training purposes, and to deter and investigate theft, misconduct, and other criminal activity.

Locations of cameras

• Video cameras are installed in common areas of dental practice, which may include the following: Reception and waiting areas, hallways, entrances and exits, areas where equipment or medications are stored, such as operatories and sterilization stations.
• No video surveillance is used in areas where there is a reasonable expectation of privacy, such as restrooms or changing rooms.

Important limitations

• Video only, no audio: California is a "two-party consent" state, and it is illegal to record confidential conversations without the consent of all parties. Therefore, our surveillance system records video only and does not capture audio.
• Protected Health Information (PHI): The cameras are positioned to avoid capturing protected health information (PHI), such as patient charts or computer screens. Any incidental capture of PHI is protected according to federal HIPAA laws and state privacy regulations.
• No patient monitoring: Video surveillance is not used to monitor or record individual patients during treatment, in exam rooms, or in private offices where confidential medical discussions occur.

Access and storage of recordings

• Limited access: Access to the video recordings is strictly limited to authorized management and security personnel.
• Secure storage: Recordings are stored securely to prevent unauthorized access. The storage system is password-protected and complies with HIPAA Security Rule requirements.
• Retention policy: Recordings are stored only for as long as reasonably required for security purposes, typically, no longer than 120 days, unless a specific recording is needed for an ongoing investigation.
• Disclosure: Video footage will only be disclosed to law enforcement or other third parties as required by law, such as with a subpoena.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy policy or have questions or concerns, please contact us. If you have concerns relating to a perceived violation of your privacy rights, to access to your health information, to amending or restricting the use or disclosure of your health information, or to requesting alternative means of communication, you may contact us using the contact information listed at the end of this Notice. You also may submit a written complaint to the Department of Health and Human Services (HHS). We will provide you with the HHS address upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the HHS.

HIPAA Coordinator: Haley Dunne
Telephone: (925) 449 - 6633
Fax: (925) 449 - 0766
Email: perioassoc@hotmail.com
Address: 4527 Livermore Outlets Drive, Livermore, Ca 94551

NOTICE Dentists are licensed and regulated by the Dental Board of California
877-729-7789
www.dbc.ca.gov

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES AND CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

Notice of Private Practices: You have the right to read our Privacy Practices before you decide whether or not to sign this consent. A copy of our Notice and/or this consent is available upon request. Our Notice provides a description of our treatment, payment activities and healthcare operations, of the uses and disclosures we make of your protected health information.

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

I have been shown a copy of this office's Notice of Privacy Practices and have had full opportunity to read and consider its contents. I understand that by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations.

Patients Name: _______________________________

Parent/Legal Guardian Name: _______________________________

Signature: _______________________________ Date: __________________

Relationship to Patient: _______________________________

For office use only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

• Individual refused to sign
• Communication barriers prohibited obtaining the acknowledgement
• Other (please specify) _______________________________