Model Notice of Privacy Practices for US practices

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.

Practice: to be filled in by the practice

In this notice, “the Practice”, “we”, “us” and “our” mean the dental practice named at the top of this notice, and “your health information” means the information about you, your health, your care and its payment that we keep, which the law calls protected health information.

Our duties

The law requires us to:

keep your health information private and secure;
give you this notice of our legal duties and privacy practices;
follow the terms of the notice that is currently in effect; and
tell you promptly if a breach occurs that may have compromised the privacy or security of your information.

We will not use or share your health information other than as this notice describes unless you tell us in writing that we can.

How we use and share your health information

For treatment

We use your health information to provide your dental care and share it with other professionals who treat you. Example: your dentist reviews your medical history and radiographs before a procedure, or sends them to a specialist or a dental laboratory working on your case.

For payment

We use and share your health information to bill and get paid for your care, by you, your health plan or others. Example: we give your dental plan information about a procedure so that it will pay for it.

For health care operations

We use and share your health information to run the Practice, improve your care and contact you when necessary. Example: we review records to check the quality of our care, train our staff, or manage our schedule.

Appointment reminders and information about your care

We may contact you, for example by email or telephone, to remind you of an appointment or a recall visit, to send you a document to read or sign, or to tell you about treatment options and health-related services that may interest you.

With people involved in your care

We may share relevant information with a family member, friend or other person involved in your care or in paying for it, or for disaster relief, unless you tell us not to. If you cannot tell us, for example because you are unconscious, we may share it if we believe it is in your best interest.

With our business associates

We share health information with companies that perform services for us, which must protect it under a written contract. Example: the provider of our practice-management software, VstreamX Studio Inc., which provides DentalX, stores our records and sends our appointment reminders.

Other uses and disclosures we may make without your authorization

The law allows or requires us to share your health information in the following ways, usually to contribute to the public good, such as public health and research. We must meet conditions in the law before we share it for these purposes.

As required by law, including to the Department of Health and Human Services when it wants to see that we are complying with federal privacy law.
Public health and safety, such as preventing disease, helping with product recalls, reporting adverse reactions to medicines, reporting suspected abuse, neglect or domestic violence, and preventing or reducing a serious threat to anyone’s health or safety.
Health oversight, to agencies for activities the law authorizes, such as audits, investigations, inspections and licensing.
Lawsuits and legal actions, in response to a court or administrative order, or to a subpoena.
Law enforcement, for law enforcement purposes or with a law enforcement official.
Medical examiners, coroners and funeral directors, when an individual dies.
Organ and tissue donation, to organ procurement organizations.
Research, where the law allows it, for example when a review board has approved it.
Workers’ compensation claims.
Special government functions, such as military and veterans’ activities, national security and intelligence, protective services for the President and others, and correctional institutions or law enforcement custody.

Uses and disclosures that require your written authorization

We never do the following unless you give us written permission:

use or share your health information for marketing;
sell your health information; or
share most psychotherapy notes, if we hold any.

Any other use or disclosure that this notice does not describe will be made only with your written authorization. You may revoke an authorization at any time by writing to our privacy officer; revoking it does not undo what we have already done in reliance on it.

Fundraising

We may contact you for fundraising efforts, but you can tell us not to contact you again.

Information with extra protection

Some laws protect certain information more strictly than HIPAA does, for example information about HIV or other communicable diseases, mental health, genetic testing, substance use disorder treatment, or the care of minors, and the laws of the state where we practice. Where such a law applies, we follow it. If we receive records of substance use disorder treatment protected by federal law (42 CFR Part 2), we will not use or share them in a civil, criminal, administrative or legislative proceeding against you without your written consent or a court order.

Your rights

You have the following rights. To use any of them, write to our privacy officer at the address on this notice; we may ask you to use a form.

Get a copy of your health and billing records

You can ask to see or get a paper or electronic copy of your health and billing records. We will give you a copy or a summary, usually within 30 days of your request, and may charge a reasonable, cost-based fee.

Ask us to correct (amend) your records

You can ask us to correct health information that you think is incorrect or incomplete. We may say no, but we will tell you why in writing within 60 days, and you may then give us a statement of disagreement.

Request confidential communications

You can ask us to contact you in a specific way, for example by home or office telephone, or to send mail to a different address. We will say yes to all reasonable requests, and we will not ask you why.

Ask us to limit what we use or share

You can ask us not to use or share certain health information for treatment, payment or our operations. We are not required to agree, and we may say no if it would affect your care. If you pay for a service or health care item out of pocket in full, you can ask us not to share that information with your health plan for payment or our operations; we will say yes unless a law requires us to share it.

Get a list of those with whom we have shared your information (an accounting)

You can ask for a list of the times we have shared your health information in the six years before your request, with whom we shared it and why. It will include all disclosures except those for treatment, payment and health care operations and certain others, such as those you asked us to make. We provide one list a year free and may charge a reasonable, cost-based fee if you ask for another within 12 months.

Get a paper copy of this notice

You can ask for a paper copy of this notice at any time, even if you agreed to receive it electronically, and we will give it to you promptly.

Choose someone to act for you

If you have given someone medical power of attorney, or someone is your legal guardian, that person can use your rights and make choices about your health information. We will make sure they have that authority before we act.

Be notified of a breach

You have the right to be notified if a breach of your unsecured health information occurs, as our duties above state.

Changes to this notice

We can change the terms of this notice, and the changes will apply to all the health information we have about you, including information we created or received before the change. The new notice will be available on request, in our office and on our website.

How to file a complaint

If you believe your privacy rights have been violated, you may complain to us by writing to our privacy officer at the address on this notice. You may also file a complaint with the Secretary of the United States Department of Health and Human Services, through its Office for Civil Rights, by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints. We will not retaliate against you for filing a complaint.

Contact for more information

For more information about our privacy practices, or to use any of your rights, contact our privacy officer:

Privacy officer (name or title): to be filled in by the practice
Telephone: to be filled in by the practice
Address: to be filled in by the practice

Effective date

This notice takes effect on Date: to be filled in by the practice. It follows the DentalX model notice published on October 2, 2026, revision 1.

For the practice adopting this model (not part of the notice)

DentalX provides this model Notice of Privacy Practices for dental practices in the United States that use DentalX. Under the Health Insurance Portability and Accountability Act (HIPAA), a notice of privacy practices is the practice’s own: the practice that gives it to its patients is responsible for it and for the practices it describes. VstreamX Studio Inc., which provides DentalX, is that practice’s business associate: it processes patient information on the practice’s behalf, under the business associate agreement it has signed with that practice, and does not decide how that information is used or shared.

To adopt it, the practice fills in the blanks: its name, the name or title of its privacy officer with a telephone number and an address, and the date the notice takes effect, which may not be earlier than the date it is first printed or posted. It leaves this box out of the copy it gives its patients. It gives the notice to each patient no later than the first visit and makes a good-faith effort to obtain the patient’s written acknowledgment of receipt; posts it in the office where patients can see it and on its website; and reviews it with its own counsel, including any state law that protects some information more than HIPAA does. This model is not legal advice. Questions about the model: admin@vstreamx.com.

If you are a patient, ask the practice that gave you its notice about your information. VstreamX cannot answer for a practice.