Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
PLEASE REVIEW THIS CAREFULLY
Our Legal Duty:
We are required by applicable federal and state law to maintain the privacy of your protected health information. We
are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your
protected health information.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are
permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our
Notice effective for all health information that we maintain, including health information we created or received before
we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and
provide the new Notice at our practice location, and we will distribute it upon request.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional
copies of this Notice, please contact us using the information listed at the end of this notice.
addition to our use of your health information for the following purposes, you may give us
written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an
authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted
by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your
health information for any reason except those described in this Notice.
Uses and Disclosures of Health Information:
We use and disclose health information about you without authorization
for the following purposes.
We may use or disclose your health information for your treatment. For example, we may disclose your
health information to a physician or other healthcare provider providing treatment to you.
We may use and disclose your health information to obtain payment for services we provide to you. For
example, we may send claims to your dental health plan containing certain health information.
We may use and disclose your health information in connection with our healthcare operations.
For example, healthcare operations include quality assessment and improvement activities, reviewing the competence
or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training
programs, accreditation, certification, licensing or credentialing activities. Disclosures may be made to business
associates with which we contract to provide services on our behalf in connection with our healthcare operations.
To You or Your Personal Representative:
We must disclose your health information to you, as described in the Patient
Rights section of this Notice. We may disclose your health information to your personal representative, but only if you
agree that we may do so.
Persons Involved In Care:
We may use or disclose health information to notify, or assist in the notification of (including
identifying or locating) a family member, your personal representative or another person responsible for your care, of
your location, your general condition, or death. If you are present, then prior to use or disclosure of your health
information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your absence
or incapacity or in emergency circumstances, we will disclose health information based on a determination using our
professional judgment disclosing only health information that is directly relevant to the person’s involvement in your
healthcare. We will also use our professional judgment and our experience with common practice to make reasonable
inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other
similar forms of health information.
We may use or disclose your health information to assist in disaster relief efforts.
Marketing Health-Related Services:
We will not use your health information for marketing communications without
your written authorization.
Required by Law:
We may use or disclose your health information when we are required to do so by law.
Public Health and Public Benefit:
We may use or disclose your health information to report abuse, neglect, or domestic
violence; to report disease, injury, and vital statistics; to report certain information to the Food and Drug Administration
(FDA); to alert someone who may be at risk of contracting or spreading a disease; for health oversight activities; for
certain judicial and administrative proceedings; for certain law enforcement purposes; to avert a serious threat to health
or safety; and to comply with workers’ compensation or similar programs.
We may disclose health information about a decedent as authorized or required by law.
We may disclose to military authorities the health information of Armed Forces personnel under
certain circumstances. We may disclose to authorized federal officials health information required for lawful
intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law
enforcement official having lawful custody the protected health information of an inmate or patient under certain
We may use or disclose your health information to provide you with appointment reminders
(such as voicemail messages, postcards, or letters).
You have the right to look at or get copies of your health information, with limited exceptions. You may request
that we provide copies in a format other than photocopies. We will use the format you request unless we cannot
practicably do so. You must make a request in writing to obtain access to your health information. You may obtain a
form to request access by using the contact information listed at the end of this Notice. You may also request access by
sending us a letter to the address at the end of this Notice. If you request copies, we will charge you in AZ, CA, HI, OK
$4.00 per x-ray and $.25 for each page or in KS, NV, OR, WA $4.00 per x-ray $.50 for each page to copy your health
information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a
cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an
explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a
full explanation of our fee structure.
You have the right to receive a list of instances in which we or our business associates disclosed
your health information for purposes other than treatment, payment, healthcare operations, and certain other
activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month
period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
You have the right to request that we place additional restrictions on our use or disclosure of your health
information. In most cases we are not required to agree to these additional restrictions, but if we do, we will abide by
our agreement (except in certain circumstances where disclosure is required or permitted, such as an emergency, for
public health activities, or when disclosure is required by law). We must comply with a request to restrict the disclosure
of protected health information to a health plan for purposes of carrying out payment or health care operations (as
defined by HIPAA) if the protected health information pertains solely to a health care item or service for which we have
been paid out of pocket in full.
You have the right to request that we communicate with you about your health
information by alternative means or at alternative locations. (You must make your request in writing.) Your request must
specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under
the alternative means or location you request.
You have the right to request that we amend your health information. Your request must be in writing,
and it must explain why the information should be amended. We may deny your request under certain circumstances.
You may receive a paper copy of this notice upon request, even if you have agreed to receive this
notice electronically on our Web site or by electronic mail (e-mail).
Questions and Complaints:
If you want more information about our privacy practices or have questions or concerns,
please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we
made about access to your health information or in response to a request you made to amend or restrict the use or
disclosure of your health information or to have us communicate with you by alternative means or at alternative
locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a
written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file
your complaint with the U.S. Department of Health and Human Services upon request.
We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a
complaint with us or with the U.S. Department of Health and Human Services.
Megan Wallace, Esq and Karen Feldman, DDS
Telephone: 310-765-2444 or 310-765-3518 Fax: 888-282-5196 or 866-769-8847
Address: 9800 S. La Cienega Blvd, Suite 800 Inglewood, CA 90301
Click here to download Acknowledgement Form.