HIPAA Notice of Privacy Practices Acknowledgement

I acknowledge that I have been offered and had the opportunity to read the Notice of Privacy Practices of this dental practice, which describes how my protected health information (PHI) may be used and disclosed for treatment, payment, and health care operations.

I understand my rights under HIPAA and California law include: (1) the right to request restrictions on certain uses and disclosures of my PHI; (2) the right to request confidential communications by alternate means or at alternate locations; (3) the right to inspect and obtain copies of my records (under California Health & Safety Code § 123110, the practice will respond within 5 business days for inspection and 15 business days for copies); (4) the right to request amendments to my records; (5) the right to an accounting of certain disclosures; (6) the right to a paper copy of the Notice of Privacy Practices upon request, even if I received it electronically; and (7) the right to be notified if there is a breach of my unsecured PHI, as required by federal and California law.

I understand that my medical information is also protected by the California Confidentiality of Medical Information Act (CMIA, Civil Code § 56 et seq.), which in some areas provides stronger protections than HIPAA. Under CMIA, the practice will not disclose my medical information to third parties without a specific written authorization from me, except where disclosure is required or specifically permitted by California law. I understand I have a private right of action under CMIA § 56.36 if my medical information is improperly disclosed.

I understand the practice is required by California Civil Code § 1798.81.5 to implement and maintain reasonable security procedures to protect my personal information from unauthorized access, destruction, use, modification, or disclosure. The practice will notify me in writing in the event of a breach as required by California Civil Code § 1798.82 and federal law.

I understand that the practice may change the terms of its Notice of Privacy Practices and the changes will apply to all health information it maintains, including information created before the change. The current Notice will be posted at the office and on the website, and a copy is available on request.

If I have selected text (SMS) or email as an acceptable contact method, I expressly consent to receiving appointment reminders, recall notices, and care-related messages at the number or address I have provided. I understand standard message and data rates may apply, that I can reply STOP to opt out of SMS at any time, and that my consent is not a condition of receiving dental care.