HIPAA
Notice of Privacy Practices
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.
Your rights
When it comes to your health information, you have certain rights. You can:
Get an electronic or paper copy of your dental record. We usually provide it within 30 days, and we may charge a reasonable, cost-based fee.
Ask us to correct your record if you think it is incorrect or incomplete. We may say no, but we’ll tell you why in writing within 60 days.
Ask us to contact you in a specific way, such as a home or office phone, or to send mail to a different address. We say yes to all reasonable requests.
Ask us to limit what we use or share. We are not required to agree. If you pay for a service in full yourself, you can ask us not to share that information with your health insurer, and we will say yes unless the law requires us to share it.
Get a list of those we’ve shared your information with in the six years before the date you ask.
Get a paper copy of this notice at any time, even if you agreed to get it electronically.
Choose someone to act for you, such as a medical power of attorney or a legal guardian.
File a complaint if you feel your rights have been violated. We will not retaliate against you for filing a complaint.
Your choices
For certain health information, you can tell us your choices about what we share. You can tell us to:
Share information with your family, close friends or others involved in your care
Share information in a disaster relief situation
If you can’t tell us your preference, for example if you are unconscious, we may share your information if we believe it is in your best interest.
We never sell your information or share it for marketing unless you give us written permission.
Our uses and disclosures
We typically use or share your health information in these ways:
To treat you. We use your information and share it with other professionals who are treating you, such as a specialist we refer you to.
To run our practice. We use your information to run the practice, improve your care and contact you when needed.
To bill for your services. We use and share your information to bill and get payment from health plans or others.
We are also allowed or required to share your information in other ways, usually for public health and safety, research, and legal reasons. Examples include preventing disease, reporting suspected abuse or neglect, responding to a court order or a lawful government request, working with a medical examiner, and workers’ compensation claims. The law sets conditions that must be met before we share for these reasons.
Our responsibilities
We are required by law to keep your protected health information private and secure.
We will let you know promptly if a breach occurs that may have put the privacy or security of your information at risk.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us in writing that we can. You can change your mind at any time. Let us know in writing if you do.
Changes to this notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available on request, in our office and on our website.
Contact and effective date
Privacy officer: Linda Kowalski, Office Manager. Ostrom Dental, 3600 Butler Street, Suite 2, Pittsburgh, PA 15201 (Sample address). Phone (412) 555-0162. Email hello@example.com.
You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by writing to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
Effective date: November 1, 2026.
Sample date
Template text
Review this notice with your HIPAA or compliance advisor before publishing, and keep a printed copy at your front desk.
This template helps you follow common rules for dental websites in the US. It is not legal advice.