Effective Date: 05/01/2026
Last Updated: 05/01/2026
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.
Our commitment to your privacy
POM Dental Hygiene Studio (“POM,” “we,” “us,” or “our”) is required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and related federal and California state laws to maintain the privacy of your protected health information (PHI) and to provide you with this notice describing our legal duties and privacy practices.
We are required to follow the terms of this notice currently in effect. We reserve the right to change the terms of this notice at any time. Any changes will apply to all PHI we maintain. If we make a material change, we will post the revised notice on our website and have copies available at our office.
How we may use and disclose your health information
We may use and disclose your PHI for the following purposes without your specific authorization:
Treatment
We may use and disclose your PHI to provide, coordinate, or manage your dental care. For example, we may share your information with a specialist we refer you to, such as a periodontist or orthodontist.
Payment
We may use and disclose your PHI to obtain payment for services. For example, we may provide documentation to your insurance company so you can submit for reimbursement, or to verify an HSA/FSA claim.
Healthcare operations
We may use and disclose your PHI for routine practice operations such as quality improvement, staff training, licensing, and accreditation activities.
Appointment reminders and health-related information
We may contact you to remind you of an appointment, provide post-visit instructions, or share information about treatments or services that may be of interest to you. You may request that we not use certain methods of contact (for example, you may request that we not leave voicemails or text you).
Required by law
We will disclose PHI when required to do so by federal, state, or local law, including reporting suspected abuse or neglect, responding to court orders or subpoenas, and reporting certain communicable diseases to public health authorities.
Other uses
Other uses and disclosures not described in this notice will be made only with your written authorization. You may revoke any authorization at any time, in writing, except to the extent we have already acted in reliance on it.
Your rights regarding your health information
You have the following rights regarding the PHI we maintain about you:
Right to inspect and copy
You have the right to inspect and request a copy of your PHI. We may charge a reasonable, cost-based fee for the copy. Requests must be made in writing to our Privacy Officer.
Right to request amendment
If you believe your PHI is incorrect or incomplete, you may request that we amend it. We may deny your request under certain circumstances.
Right to an accounting of disclosures
You have the right to request a list of disclosures we made of your PHI, other than disclosures for treatment, payment, or healthcare operations, and certain other exceptions.
Right to request restrictions
You have the right to request that we restrict the use or disclosure of your PHI for treatment, payment, or healthcare operations. We are not required to agree to your request, except in limited circumstances.
Right to request confidential communications
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you may ask that we only contact you at work or by mail.
Right to a paper copy of this notice
You have the right to receive a paper copy of this notice at any time, even if you have agreed to receive it electronically.
Right to be notified of a breach
You have the right to be notified if there is a breach of your unsecured PHI.
California-specific rights
California residents may have additional rights under the California Confidentiality of Medical Information Act (CMIA) and other state laws. For more information about your California-specific rights, please contact our Privacy Officer.
How to exercise your rights
To exercise any of the rights described in this notice, please submit a written request to:
POM Dental Hygiene Studio
Attn: Privacy Officer
Address:
Encinitas, CA 92024
Phone: (555) 123-4567
Email: hello@pomdentalstudio.com
Complaints
If you believe your privacy rights have been violated, you may file a complaint with:
POM Dental Hygiene Studio
Contact our Privacy Officer at the address and phone number above. We will not retaliate against you for filing a complaint.
U.S. Department of Health and Human Services
You may file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights:
200 Independence Avenue, S.W.
Washington, D.C. 20201
Phone: 1-877-696-6775
Website: hhs.gov/ocr/privacy/hipaa/complaints/
Acknowledgment
Federal law requires us to provide you with this notice and to obtain a written acknowledgment that you have received it. You will be asked to sign an acknowledgment form at your first visit. Your signature is not consent to our use of your PHI — it only confirms you have received the notice.