OMNIBUS Rule

HIPAA NOTICE OF PRIVACY PRACTICES

for the Facility of:

Name of Facility: iTooth Dentistry
Address: 7035 N Chestnut Ave, Ste 107 Fresno, CA 93720

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION under the HIPAA Omnibus Rule of 2013.

PLEASE REVIEW IT CAREFULLY

For purposes of this Notice “us” “we” and “our” refers to the Name of this Healthcare Facility: iTooth Dentistry and “you” or “your” refers to our patients (or their legal representatives as determined by us in accordance with state informed consent law). When you receive healthcare services from us, we will obtain access
to your medical information (i.e. your health history). We are committed to maintaining the privacy of your health
information and we have implemented numerous procedures to ensure that we do so.

 

The Federal Health Insurance Portability & Accountability Act of 2013, HIPAA Omnibus Rule, (formally HIPAA 1996 & HI TECH of 2004) require us to maintain the confidentiality of all your healthcare records and other identifiable patient health information (PHI) used by or disclosed to us in any form, whether electronic, on paper, or spoken. HIPAA is a Federal Law that gives you significant new rights to understand and control how your health information
is used. Federal HIPAA Omnibus Rule and state law provide penalties for covered entities, business associates, and their subcontractors and records owners, respectively that misuse or improperly disclose PHI. Starting April 14, 2003, HIPAA requires us to provide you with the Notice of our legal duties and the privacy practices we are required to follow when you first come into our office for health-care services. If you have any questions about this Notice, please ask to speak to our HIPAA Privacy Officer. Our doctors, clinical staff, employees, Business Associates (outside contractors we hire), their subcontractors and
other involved parties follow the policies and procedures set forth in this Notice. If at this facility, your primary caretaker / doctor is unavailable to assist you (i.e. illness, on-call coverage, vacation, etc.), we may provide you with the name of another healthcare provider outside our practice for you to consult with. If we do so, that provider will follow the policies and procedures set forth in this Notice or those established for his or her practice, so long as they substantially conform to those for our practice.

OUR RULES ON HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION
Under the law, we must have your signature on a written, dated Consent Form and/or an Authorization Form of Acknowledgement of this Notice, before we will use or disclose your PHI for certain purposes as detailed in the rules below. Documentation—You will be asked to sign an Authorization / Acknowledgement form when you receive this Notice of Privacy Practices. If you did not sign such a form or need a copy of the one you signed, please contact our Privacy Officer. You may take back or revoke your consent or authorization at any time (unless we already have acted based on it) by submitting our Revocation Form in writing to us at our address listed above. Your revocation will take effect when we actually receive it. We cannot give it retroactive effect, so it will not affect any use or disclosure that occurred in our reliance on your Consent or Authorization prior to revocation (i.e. if after we provide services to you, you revoke your authorization / acknowledgement in order to prevent us billing or collecting for those services, your revocation will have no effect because we relied on your authorization/ acknowledgement to provide services before you revoked it). General Rule—If you do not sign our authorization/ acknowledgement form or if you revoke it, as a general rule (subject to exceptions described below under “Healthcare Treatment, Payment and Operations Rule” and “Special Rules”), we cannot in any manner use or disclose to anyone (excluding you, but including payers and Business Associates) your PHI or any other information in your medical record. By law, we are unable to submit claims to payers under assignment of benefits without your signature on our authorization/ acknowledgement form. You
will however be able to restrict disclosures to your insurance carrier for services for which you wish to pay “out of pocket” under the new Omnibus Rule. We will not condition treatment on you signing an authorization / acknowledgement, but we may be forced to decline you as a new patient or discontinue you as an active patient if you choose not to sign the authorization/ acknowledgement or revoke it.

Healthcare Treatment, Payment and Operations Rule
With your signed consent, we may use or disclose your PHI in order:
➧ To provide you with or coordinate healthcare treatment and services. For example, we may review your
health history form to form a diagnosis and treatment plan, consult with other doctors about your care,
delegate tasks to ancillary staff, call in prescriptions to your pharmacy, disclose needed information to your

family or others so they may assist you with home care, arrange appointments with other healthcare providers, schedule lab work for you, etc.

➧ To bill or collect payment from you, an insurance company, a managed-care organization, a health benefits
plan or another third party. For example, we may need to verify your insurance coverage, submit your PHI

on claim forms in order to get reimbursed for our services, obtain pre-treatment estimates or prior authorizations from your health plan or provide your x-rays because your health plan requires them for payment; Remember, you will be able to restrict disclosures to your insurance carrier for services for which you wish
to pay “out of pocket” under this new Omnibus Rule.
➧ To run our office, assess the quality of care our patients receive and provide you with customer service. For
example, to improve efficiency and reduce costs associated with missed appointments, we may contact
you by telephone, mail or otherwise remind you of scheduled appointments, we may leave messages with
whomever answers your telephone or email to contact us (but we will not give out detailed PHI), we may
call you by name from the waiting room, we may ask you to put your name on a sign-in sheet, (we will
cover your name just after checking you in), we may tell you about or recommend health-related products
and complementary or alternative treatments that may interest you, we may review your PHI to evaluate
our staff’s performance, or our Privacy Officer may review your records to assist you with complaints. If you
prefer that we not contact you with appointment reminders or information about treatment alternatives or
health-related products and services, please notify us in writing at our address listed above and we will not
use or disclose your PHI for these purposes.
➧ New HIPAA Omnibus Rule does not require that we provide the above notice regarding Appointment
Reminders, Treatment Information or Health Benefits, but we are including these as a courtesy so you
understand our business practices with regards to your (PHI) protected health information.

Additionally, you should be made aware of these protection laws on your behalf, under the new HIPAA Omnibus Rule:
➧ That Health Insurance plans that underwrite cannot use or disclose genetic information for underwriting
purposes (this excludes certain long-term care plans). Health plans that post their NOPPs on their web sites
must post these Omnibus Rule changes on their sites by the effective date of the Omnibus Rule, as well as
notify you by US Mail by the Omnibus Rules effective date. Plans that do not post their NOPPs on their Web
sites must provide you information about Omnibus Rule changes within 60 days of these federal revisions.
➧ Psychotherapy Notes maintained by a healthcare provider, must state in their NOPPs that they can allow
“use and disclosure” of such notes only with your written authorization.
Special Rules
Notwithstanding anything else contained in this Notice, only in accordance with applicable HIPAA Omnibus Rule,
and under strictly limited circumstances, we may use or disclose your PHI without your permission, consent or
authorization for the following purposes:
➧ When required under federal, state or local law
➧ When necessary in emergencies to prevent a serious threat to your health and safety or the health and
safety of other persons
➧ When necessary for public health reasons (i.e. prevention or control of disease, injury or disability, reporting

information such as adverse reactions to anesthesia, ineffective or dangerous medications or products, sus-
pected abuse, neglect or exploitation of children, disabled adults or the elderly, or domestic violence)

➧ For federal or state government health-care oversight activities (i.e. civil rights laws, fraud and abuse inves-
tigations, audits, investigations, inspections, licensure or permitting, government programs, etc.)

➧ For judicial and administrative proceedings and law enforcement purposes (i.e. in response to a warrant,
subpoena or court order, by providing PHI to coroners, medical examiners and funeral directors to locate
missing persons, identify deceased persons or determine cause of death)
➧ For Worker’s Compensation purposes (i.e. we may disclose your PHI if you have claimed health benefits for
a work-related injury or illness)

➧ For intelligence, counterintelligence or other national security purposes (i.e. Veterans Affairs, U.S. military com-
mand, other government authorities or foreign military authorities may require us to release PHI about you)

➧ For organ and tissue donation (i.e. if you are an organ donor, we may release your PHI to organizations that
handle organ, eye or tissue procurement, donation and transplantation)

➧ For research projects approved by an Institutional Review Board or a privacy board to ensure confidential-
ity (i.e. if the researcher will have access to your PHI because involved in your clinical care, we will ask you to

sign an authorization)
➧ To create a collection of information that is “de-identified” (i.e. it does not personally identify you by name,
distinguishing marks or otherwise and no longer can be connected to you)
➧ To family members, friends and others, but only if you are present and verbally give permission. We give

you an opportunity to object and if you do not, we reasonably assume, based on our professional judgment and the surrounding circumstances, that you do not object (i.e. you bring someone with you into the operatory or exam room during treatment or into the conference area when we are discussing your PHI); we reasonably infer that it is in your best interest (i.e. to allow someone to pick up your records because they knew you were our patient and you asked them in writing with your signature to do so); or it is an
emergency situation involving you or another person (i.e. your minor child or ward) and, respectively, you cannot consent to your care because you are incapable of doing so or you cannot consent to the other person’s care because, after a reasonable attempt, we have been unable to locate you. In these emergency sit-
uations we may, based on our professional judgment and the surrounding circumstances, determine that disclosure is in the best interests of you or the other person, in which case we will disclose PHI, but only as
it pertains to the care being provided and we will notify you of the disclosure as soon as possible after the
care is completed. As per HIPAA law 164.512(j) (i)… (A) Is necessary to prevent or lessen a serious or
imminent threat to the health and safety of a person or the public and (B) Is to person or persons
reasonably able to prevent or lessen that threat.
Minimum Necessary Rule
Our staff will not use or access your PHI unless it is necessary to do their jobs (i.e. doctors uninvolved in your care
will not access your PHI; ancillary clinical staff caring for you will not access your billing information; billing staff will
not access your PHI except as needed to complete the claim form for the latest visit; janitorial staff will not access
your PHI). All of our team members are trained in HIPAA Privacy rules and sign strict Confidentiality Contracts with
regards to protecting and keeping private your PHI. So do our Business Associates (and their Subcontractors). Know
that your PHI is protected several layers deep with regards to our business relations. Also, we disclose to others
outside our staff, only as much of your PHI as is necessary to accomplish the recipient’s lawful purposes. Still in
certain cases, we may use and disclose the entire contents of your medical record:
➧ To you (and your legal representatives as stated above) and anyone else you list on a Consent or
Authorization to receive a copy of your records
➧ To healthcare providers for treatment purposes (i.e. making diagnosis and treatment decisions or
agreeing with prior recommendations in the medical record)
➧ To the U.S. Department of Health and Human Services (i.e. in connection with a HIPAA complaint)
➧ To others as required under federal or state law
➧ To our privacy officer and others as necessary to resolve your complaint or accomplish your
request under HIPAA (i.e. clerks who copy records need access to your entire medical record)
In accordance with HIPAA law, we presume that requests for disclosure of PHI from another Covered Entity (as defined
in HIPAA) are for the minimum necessary amount of PHI to accomplish the requestor’s purpose. Our Privacy Officer
will individually review unusual or non-recurring requests for PHI to determine the minimum necessary amount
of PHI and disclose only that. For non-routine requests or disclosures, our Privacy Officer will make a minimum
necessary determination based on, but not limited to, the following factors:
➧ The amount of information being disclosed
➧ The number of individuals or entities to whom the information is being disclosed
➧ The importance of the use or disclosure
➧ The likelihood of further disclosure
➧ Whether the same result could be achieved with de-identified information
➧ The technology available to protect confidentiality of the information

➧ The cost to implement administrative, technical and security procedures to protect confidentiality
If we believe that a request from others for disclosure of your entire medical record is unnecessary, we will ask the
requestor to document why this is needed, retain that documentation and make it available to you upon request.
Incidental Disclosure Rule
We will take reasonable administrative, technical and security safeguards to ensure the privacy of your PHI when we
use or disclose it (i.e. we shred all paper containing PHI, require employees to speak with privacy precautions when
discussing PHI with you, we use computer passwords and change them periodically (i.e. when an employee leaves
us), we use firewall and router protection to the federal standard, we back up our PHI data off-site and encrypted
to federal standard, we do not allow unauthorized access to areas where PHI is stored or filed and/or we have any
unsupervised business associates sign Business Associate Confidentiality Agreements).
However, in the event that there is a breach in protecting your PHI, we will follow Federal Guide Lines to HIPAA
Omnibus Rule Standard to first evaluate the breach situation using the Omnibus Rule, 4-Factor Formula for Breach
Assessment. Then we will document the situation, retain copies of the situation on file, and report all breaches (other
than low probability as prescribed by the Omnibus Rule) to the US Department of Health and Human Services at:

http://www.hhs.gov/hipaa/for-professionals/breach-notification/breach-reporting/index.html (If this link is bro-
ken, for updated link, Google Search: HIPAA Breach Reporting HHS)

We will also make proper notification to you and any other parties of significance as required by HIPAA Law.
Business Associate Rule
Business Associates are defined as: an entity, (non-employee) that in the course of their work will directly / indirectly
use, transmit, view, transport, hear, interpret, process or offer PHI for this Facility.

Business Associates and other third parties (if any) that receive your PHI from us will be prohibited from re-disclos-
ing it unless required to do so by law or you give prior express written consent to the re-disclosure. Nothing in

our Business Associate agreement will allow our Business Associate to violate this re-disclosure prohibition. Under

Omnibus Rule, Business Associates will sign a strict confidentiality agreement binding them to keep your PHI pro-
tected and report any compromise of such information to us, you and the United States Department of Health

and Human Services, as well as other required entities. Our Business Associates will also follow Omnibus Rule and
have any of their Subcontractors that may directly or indirectly have contact with your PHI, sign Confidentiality
Agreements to Federal Omnibus Standard.
Super-confidential Information Rule
If we have PHI about you regarding communicable diseases, disease testing, alcohol or substance abuse diagnosis
and treatment, or psychotherapy and mental health records (super-confidential information under the law), we
will not disclose it under the General or Healthcare Treatment, Payment and Operations Rules (see above) without

your first signing and properly completing our Consent form (i.e. you specifically must initial the type of super-con-
fidential information we are allowed to disclose). If you do not specifically authorize disclosure by initialing the

super-confidential information, we will not disclose it unless authorized under the Special Rules (see above) (i.e.

we are required by law to disclose it). If we disclose super-confidential information (either because you have ini-
tialed the consent form or the Special Rules authorizing us to do so), we will comply with state and federal law that

requires us to warn the recipient in writing that re-disclosure is prohibited.
Changes to Privacy Policies Rule
We reserve the right to change our privacy practices (by changing the terms of this Notice) at any time as authorized by law. The changes will be effective immediately upon us making them. They will apply to all PHI we create or
receive in the future, as well as to all PHI created or received by us in the past (i.e. to PHI about you that we had
before the changes took effect). If we make changes, we will post the changed Notice, along with its effective date,
in our office and on our website. Also, upon request, you will be given a copy of our current Notice.
Authorization Rule
We will not use or disclose your PHI for any purpose or to any person other than as stated in the rules above without
your signature on our specifically worded, written Authorization / Acknowledgement Form (not a Consent or an
Acknowledgement). If we need your Authorization, we must obtain it via a specific Authorization Form, which may
be separate from any Authorization / Acknowledgement we may have obtained from you. We will not condition
your treatment here on whether you sign the Authorization (or not).
Marketing and Fund Raising Rules
Limitations on the disclosure of PHI regarding Remuneration
The disclosure or sale of your PHI without authorization is prohibited. Under the new HIPAA Omnibus Rule, this would
exclude disclosures for public health purposes, for treatment / payment for healthcare, for the sale, transfer, merger, or
consolidation of all or part of this facility and for related due diligence, to any of our Business Associates, in connection
with the business associate’s performance of activities for this facility, to a patient or beneficiary upon request, and as
required by law. In addition, the disclosure of your PHI for research purposes or for any other purpose permitted by
HIPAA will not be considered a prohibited disclosure if the only reimbursement received is “a reasonable, cost-based
fee” to cover the cost to prepare and transmit your PHI which would be expressly permitted by law. Notably, under
the Omnibus Rule, an authorization to disclose PHI must state that the disclosure will result in remuneration to the
Covered Entity.
Limitation on the Use of PHI for Paid Marketing
We will, in accordance with Federal and State Laws, obtain your written authorization to use or disclose your PHI for

marketing purposes, (i.e.: to use your photo in ads) but not for activities that constitute treatment or healthcare oper-
ations. To clarify, Marketing is defined by HIPAA’s Omnibus Rule, as “a communication about a product or service that

encourages recipients . . . to purchase or use the product or service.” A communication is not considered “marketing” if
it is in writing and if we do not receive direct or indirect remuneration from a third party for making the communication.
Under Omnibus Rule we will obtain your written authorization prior to using your PHI for making any treatment or
healthcare recommendations, should financial remuneration for making the communication be involved from a
third party whose product or service we might promote (i.e.: businesses offering this facility incentives to promote
their products or services to you). This will also apply to our Business Associate who may receive such remuneration
for making a treatment or healthcare recommendations to you.

We must clarify to you that financial remuneration does not include “in-kind payments” and payments for a pur-
pose to implement a disease management program. Any promotional gifts of nominal value are not subject to

the authorization requirement.
The Privacy Rule expressly excludes from the definition of “marketing” refill reminders or other communications about
a drug or biologic that is currently being prescribed for you, provided that the financial remuneration received by us
in exchange for making the communication, if any, is reasonably related to our cost of making the communication.
Face-to-face marketing communications, such as sharing with you, a written product brochure or pamphlet, is
permissible under current HIPAA Law.

Flexibility on the Use of PHI for Fundraising
Under the HIPAA Omnibus Rule, covered entities were provided more flexibility concerning the use of PHI for fund

raising efforts. However, we will offer the opportunity for you to “opt out” of receiving future fundraising commu-
nications. Simply let us know that you want to “opt out” of such situations. There will be a statement on your HIPAA

Patient Acknowledgement Form where you can choose to “opt out”. Our commitment to care and treat you will
in no way effect your decision to participate or not participate in our fund raising efforts.
Improvements to Requirements for Authorizations Related to Research

Under HIPAA Omnibus Rule, we may seek authorizations from you for the use of your PHI for future research. How-
ever, we would have to make clear what those uses are in detail.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
If you received this Notice via email or website, you have the right to get, at any time, a paper copy by asking our
Privacy Officer. Also, you have the following additional rights regarding PHI we maintain about you:
To Inspect and Copy
You have the right to see and get a copy of your PHI including, but not limited to, medical and billing records by
submitting a written request to our Privacy Officer. Original records will not leave the premises, will be available for
inspection only during our regular business hours, and only if our Privacy Officer is present at all times. You may
ask us to give you the copies in a format other than photocopies (and we will do so unless we determine that it is
impractical) or ask us to prepare a summary in lieu of the copies. We may charge you a fee not to exceed state law
to recover our costs (including postage, supplies, and staff time as applicable, but excluding staff time for search

and retrieval) to duplicate or summarize your PHI. We will not condition release of the copies on summary of pay-
ment of your outstanding balance for professional services if you have one). We will comply with Federal Law to

provide your PHI in an electronic format within the 30 days, to Federal specification, when you provide us with
proper written request. Paper copy will also be made available. We will respond to requests in a timely manner,
without delay for legal review, or, in less than thirty days if submitted in writing, and in ten business days or less if
malpractice litigation or pre-suit production is involved. We may deny your request in certain limited circumstances
(i.e. we do not have the PHI, it came from a confidential source, etc.). If we deny your request, you may ask for a
review of that decision. If required by law, we will select a licensed health-care professional (other than the person
who denied your request initially) to review the denial and we will follow his or her decision.
To Request Amendment / Correction
If you think PHI we have about you is incorrect, or that something important is missing from your records, you may
ask us to amend or correct it (so long as we have it) by submitting a “Request for Amendment / Correction” form
to our Privacy Officer. We will act on your request within 30 days from receipt but we may extend our response
time (within the 30-day period) no more than once and by no more than 30 days, or as per Federal Law allowances,
in which case we will notify you in writing why and when we will be able to respond. If we grant your request, we

will let you know within five business days, make the changes by noting (not deleting) what is incorrect or incom-
plete and adding to it the changed language, and send the changes within 5 business days to persons you ask us

to and persons we know may rely on incorrect or incomplete PHI to your detriment. We may deny your request
under certain circumstances (i.e. it is not in writing, it does not give a reason why you want the change, we did not
create the PHI you want changed (and the entity that did can be contacted), it was compiled for use in litigation,
or we determine it is accurate and complete). If we deny your request, we will (in writing within 5 business days)
tell you why and how to file a complaint with us if you disagree, that you may submit a written disagreement with
our denial (and we may submit a written rebuttal and give you a copy of it), that you may ask us to disclose your
initial request and our denial when we make future disclosure of PHI pertaining to your request, and that you may
complain to us and the U.S. Department of Health and Human Services.

You may ask us for a list of those who got your PHI from us by submitting a “Request for Accounting of Disclo-
sures” form to us. The list will not cover certain disclosures (i.e. PHI given to you, given to your legal representa-
tive, given to others for treatment, payment or health-care-operations purposes). Your request must state in what

form you want the list (i.e. paper or electronically) and the time period you want us to cover, which may be up to
but not more than the last six years. If we maintain your PHI in an electronic health record, then we must provide
you with routine disclosures of PHI, including disclosures of treatment, payment or healthcare operations, for the
3-year period prior to the date of the request. If you ask us for this list more than once in a 12-month period, we
may charge you a reasonable, cost-based fee to respond, in which case we will tell you the cost before we incur it
and let you choose if you want to withdraw or modify your request to avoid the cost.
To Request Restrictions
You may ask us to limit how your PHI is used and disclosed (i.e. in addition to our rules as set forth in this Notice)
by submitting a written “Request for Restrictions on Use, Disclosure” form to us (i.e. you may not want us to
disclose your surgery to family members or friends involved in paying for our services or providing your home
care). If we agree to these additional limitations, we will follow them except in an emergency where we will not
have time to check for limitations. Also, in some circumstances we may be unable to grant your request (e.g. we
are required by law to use or disclose your PHI in a manner that you want restricted).

To Request Alternative Communications
You may ask us to communicate with you in a different way or at a different place by submitting a written “Request
for Alternative Communication” Form to us. We will not ask you why and we will accommodate all reasonable
requests (which may include: to send appointment reminders in closed envelopes rather than by postcards, to
send your PHI to a post office box instead of your home address, to communicate with you at a telephone number
other than your home number). You must tell us the alternative means or location you want us to use and explain
to our satisfaction how payment to us will be made if we communicate with you as you request.

To Complain or Get More Information
We will follow our rules as set forth in this Notice. If you want more information or if you believe your privacy rights
have been violated (i.e. you disagree with a decision of ours about inspection / copying, amendment / correction,
accounting of disclosures, restrictions or alternative communications), we want to make it right. We never will
penalize you for filing a complaint. To do so, please file a formal, written complaint within 180 days with:
The U.S. Department of Health & Human Services Office of Civil Rights
200 Independence Ave., S.W., Washington, DC 20201
877.696.6775
Or, submit a written Complaint form to us at the following address:
Our Privacy Officer: Carlos Mendoza

Office Name:iTooth Dentistry
Office Address: 7035 N . Chestnut Ave, Ste 107 Fresno, CA 93720_________
Office Phone:559-298-3200      Office Fax: 559-493-5054
Email Address:   dds@itoothfresno.com
You may get your “HIPAA Complaint” form by calling our privacy officer.