I. Dental Practice Covered by this Notice
This Notice describes the privacy practices of Kim Rosen, DDS (“Dental Practice”).
“We” and “our” means the Dental Practice. “You” and “your” means our patient.
II. How to Contact Us/Our Privacy Official
If you have any questions or would like further information about this Notice, you can
contact Kim Rosen, DDS’ Privacy Official at:
27420 Tourney Road, Ste 270
Valencia, CA 91355
661-430-0390
III. Our Promise to You and Our Legal Obligations
The 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, including
demographic 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 that
information; 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 Information
The following examples describe different ways we may use or disclose your health
information. These examples are not meant to be exhaustive. We are permitted by law
to use and disclose your health information for the following purposes:
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A. Common Uses and Disclosures
1. Treatment. We may use your health information to provide you with dental treatment
or services, such as cleaning or examining your teeth or performing dental procedures.
We may disclose health information about you to dental specialists, physicians, or other
health care professionals involved in your care.
2. Payment. We may use and disclose your health information to obtain payment from
health plans and insurers for the care that we provide to you.
3. Health Care Operations. We may use and disclose health information about you in
connection with health care operations necessary to run our practice, including review
of our treatment and services, training, evaluating the performance of our staff and
health 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 when
contacting you to remind you of a dental appointment. We may contact you by using a
postcard, letter, phone call, voice message, text or email.
5. Treatment Alternatives and Health-Related Benefits and Services. We may use
and disclose your health information to tell you about treatment options or alternatives
or health-related benefits and services that may be of interest to you.
6. Disclosure to Family Members and Friends. We may disclose your health
information to a family member or friend who is involved with your care or payment for
your care if you do not object or, if you are not present, we believe it is in your best
interest to do so.
7. Disclosure to Business Associates. We may disclose your protected health
information to our third-party service providers (called, “business associates”) that
perform functions on our behalf or provide us with services if the information is
necessary for such functions or services. For example, we may use a business
associate to assist us in maintaining our practice management software. All of our
business associates are obligated, under contract with us, to protect the privacy of your
information and are not allowed to use or disclose any information other than as
specified in our contract.
B. Less Common Uses and Disclosures
1. Disclosures Required by Law. We may use or disclose patient health information to
the extent we are required by law to do so. For example, we are required to disclose
patient health information to the U.S. Department of Health and Human Services so that
it can investigate complaints or determine our compliance with HIPAA.
2. Public Health Activities. We may disclose patient health information for public
health activities and purposes, which include: preventing or controlling disease, injury or
disability; reporting births or deaths; reporting child abuse or neglect; reporting adverse
reactions 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 for
contracting or spreading a disease or condition.
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3. Victims of Abuse, Neglect or Domestic Violence. We may disclose health
information to the appropriate government authority about a patient whom we believe is
a victim of abuse, neglect or domestic violence.
4. Health Oversight Activities. We may disclose patient health information to a health
oversight agency for activities necessary for the government to provide appropriate
oversight of the health care system, certain government benefit programs, and
compliance with certain civil rights laws.
5. Lawsuits and Legal Actions. We may disclose patient health information in
response to (i) a court or administrative order or (ii) a subpoena, discovery request, or
other lawful process that is not ordered by a court if efforts have been made to notify the
patient or to obtain an order protecting the information requested.
6. Law Enforcement Purposes. We may disclose your health information to a law
enforcement official for a law enforcement purposes, such as to identify or locate a
suspect, material witness or missing person or to alert law enforcement of a crime.
7. Coroners, Medical Examiners and Funeral Directors. We may disclose your
health information to a coroner, medical examiner or funeral director to allow them to
carry out their duties.
8. Organ, Eye and Tissue Donation. We may use or disclose your health information
to organ procurement organizations or others that obtain, bank or transplant cadaveric
organs, eyes or tissue for donation and transplant.
9. Research Purposes. We may use or disclose your information for research
purposes pursuant to patient authorization waiver approval by an Institutional Review
Board or Privacy Board.
10. Serious Threat to Health or Safety. We may use or disclose your health
information if we believe it is necessary to do so to prevent or lessen a serious threat to
anyone’s health or safety.
11. Specialized Government Functions. We may disclose your health information to
the military (domestic or foreign) about its members or veterans, for national security
and protective services for the President or other heads of state, to the government for
security clearance reviews, and to a jail or prison about its inmates.
12. Workers’ Compensation. We may disclose your health information to comply with
workers’ compensation laws or similar programs that provide benefits for work-related
injuries or illness.
VI. Your Written Authorization for Any Other Use or Disclosure of Your Health
Information
Uses and disclosures of your protected health information that involve the release of
psychotherapy notes (if any), marketing, sale of your protected health information, or
other uses or disclosures not described in this notice will be made only with your written
authorization, unless otherwise permitted or required by law. You may revoke this
authorization at any time, in writing, except to the extent that this office has taken an
action in reliance on the use of disclosure indicated in the authorization. If a use or
disclosure of protected health information described above in this notice is prohibited or
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materially limited by other laws that apply to use, we intend to meet the requirements of
the 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 have
about you (information in a Designated Record Set as defined by HIPAA). To exercise
any of these rights, you must submit a written request to our Privacy Official listed on
the 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 deny
your request under certain circumstances. You will receive written notice of a denial and
can appeal it. We will provide a copy of your health information in a format you request
if it is readily producible. If not readily producible, we will provide it in a hard copy format
or other format that is mutually agreeable. If your health information is included in an
Electronic Health Record, you have the right to obtain a copy of it in an electronic format
and 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 your
health information.
B. Right to Amend
If you believe that your health information is incorrect or incomplete, you may request
that we amend it. We may deny your request under certain circumstances. You will
receive written notice of a denial and can file a statement of disagreement that will be
included 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 your
care or the payment for your care. We may not (and are not required to) agree to your
requested restrictions, with one exception: If you pay out of your pocket in full for a
service you receive from us and you request that we not submit the claim for this
service to your health insurer or health plan for reimbursement, we must honor that
request.
D. Right to Confidential Communications, Alternative Means and Locations
You may request to receive communications of health information by alternative means
or at an alternative location. We will accommodate a request if it is reasonable and you
indicate that communication by regular means could endanger you. When you submit a
written request to the Privacy Official listed on the first page of this Notice, you need to
provide an alternative method of contact or alternative address and indicate how
payment 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 for
the six (6) years prior to the date that the accounting is requested except for disclosures
to carry out treatment, payment, health care operations (and certain other exceptions as
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provided by HIPAA). The first accounting we provide in any 12-month period will be
without charge to you. We may charge a reasonable fee to cover the cost for each
subsequent request for an accounting within the same 12-month period. We will notify
you in advance of this fee and you may choose to modify or withdraw your request at
that 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 paper
copy of the Notice at any time (even if you have agreed to receive the Notice
electronically). 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 information
has been breached. The notification will occur by first class mail within sixty (60) days of
the event. A breach occurs when there has been an unauthorized use or disclosure
under HIPAA that compromises the privacy or security of your health information.
The breach notification will contain the following information: (1) a brief description of
what happened, including the date of the breach and the date of the discovery of the
breach; (2) the steps you should take to protect yourself from potential harm resulting
from the breach; and (3) a brief description of what we are doing to investigate the
breach, mitigate losses, and to protect against further breaches.
VIII. Special Protections for HIV, Alcohol and Substance Abuse, Mental Health and
Genetic Information
Certain federal and state laws may require special privacy protections that restrict the
use and disclosure of certain health information, including HIV-related information,
alcohol and substance abuse information, mental health information, and genetic
information. For example, a health plan is not permitted to use or disclose genetic
information for underwriting purposes. Some parts of this HIPAA Notice of Privacy
Practices may not apply to these types of information. If your treatment involves this
information, 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 will
apply to the health information we have about you or create or receive in the future. We
will promptly revise the Notice when there is a material change to the uses or
disclosures, individual’s rights, our legal duties, or other privacy practices discussed in
this Notice. We will post the revised Notice on our website (if applicable) and in our
office and will provide a copy of it to you on request. The effective date of this Notice is
04/15/2018.
X. How to Make Privacy Complaints
If you have any complaints about your privacy rights or how your health information has
been used or disclosed, you may file a complaint with us by contacting our Privacy
Official listed on the first page of this Notice.
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You may also file a written complaint with the Secretary of the U.S. Department of
Health and Human Services, Office for Civil Rights. We will not retaliate against you in
any way if you choose to file a complaint.
