Notice of privacy practices.

San Fernando Pacoima Family Dental 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, to notify you following a breach of unsecured PHI, and to follow the terms of the notice currently in effect.

How we may use and disclose your information

Treatment

We use and share your health information to provide care — for example, with specialists, dental laboratories or pharmacies involved in your treatment.

Payment

We use and share information to bill and receive payment from you, your insurance plan or Denti-Cal — for example, sending claims or pre-treatment estimates.

Health care operations

We may use information to run our practice, improve quality of care, train staff and contact you with appointment reminders.

Other uses and disclosures

We may also share your information without your written authorization when permitted or required by law, including:

• With family members or others involved in your care, if you do not object
• For public health and safety, such as preventing disease or reporting abuse
• To comply with the law, court orders, or health oversight activities
• For workers' compensation claims and certain government functions
• To avert a serious threat to health or safety

We will not use or share your information for marketing, sell it, or share psychotherapy notes without your written permission. You may revoke an authorization in writing at any time.

Your rights

• Get a copy of your dental and health records, electronic or paper. We may charge a reasonable, cost-based fee.
• Ask us to correct information you believe is incorrect or incomplete.
• Request confidential communications — for example, contacting you at a different phone number or address.
• Ask us to limit what we use or share. We are not required to agree, except that we must agree not to share with your health plan information about services you paid for in full out of pocket, if you ask.
• Get a list of certain disclosures we've made in the past six years.
• Get a copy of this notice at any time, even if you agreed to receive it electronically.
• Choose someone to act for you, such as a legal guardian or someone with medical power of attorney.

Your choices

You can tell us whether we may share information with family, close friends or others involved in your care, and how you'd like to receive appointment reminders. If you are unable to tell us (for example, if you are unconscious), we may share information if we believe it is in your best interest.

Changes to this notice

We may change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available at our office and on this website.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with us by contacting our office, or with the U.S. Department of Health and Human Services Office for Civil Rights at 200 Independence Avenue, S.W., Washington, D.C. 20201, by calling 1-877-696-6775, or online at hhs.gov/ocr/complaints. We will not retaliate against you for filing a complaint.

Contact

Privacy Officer, San Fernando Pacoima Family Dental
11208 Glenoaks Blvd, Pacoima, CA 91331
Phone: 818.890.1000 · Email: appointments@sfpacoimadental.com

A printed copy of this notice is available at our front desk. Sign the acknowledgement form.