Hollywood Smiles Family Dentistry

1869 North 66th Avenue, Hollywood, FL 33024  |  Privacy Officer: Marcela Newman DDS MS PA

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW DENTAL AND HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations (TPO) and for other purposes permitted or required by law. "Protected health information" means information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or mental health or condition and related health care services.

At a Glance

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Treatment:

We will use and disclose your protected health information to provide, coordinate, or manage your dental care and related services, including coordination with specialists or other providers to whom you have been referred.

Payment:

We will use your protected health information, as needed, to obtain payment for your health care services — for example, to obtain approval from your health plan for a covered procedure.

Healthcare Operations:

We may use or disclose your protected health information as needed to support our practice operations, including quality assessment, employee review activities, licensing, and contacting you to remind you of your appointment.

Other Permitted Disclosures Without Authorization:

We may also use or disclose your information without your authorization when required by law, for public health issues, communicable diseases, health oversight, abuse or neglect reporting, FDA requirements, legal proceedings, law enforcement, research, and other legally mandated purposes. All other permitted or required disclosures will be made only with your consent, authorization, or opportunity to object.

You may revoke any authorization at any time, in writing, except to the extent that our practice has already taken action in reliance on that authorization.

SPECIAL PROTECTIONS FOR SUBSTANCE USE DISORDER RECORDS (42 CFR PART 2)

To the extent that we have your substance use disorder patient records subject to 42 CFR Part 2, the following additional protections apply:

• Consent for Treatment, Payment, and Operations: We require your written consent for most uses and disclosures of Part 2 records, including for treatment, payment, and health care operations.
• Investigations and Legal Proceedings: We will not use or share Part 2 records for civil, criminal, administrative, or legislative investigations or proceedings against you without (1) your written consent or (2) a court order accompanied by a subpoena or other legal mandate.
• Medical Emergencies: We may share Part 2 information without your consent only in the event of a genuine medical emergency, and only with the personnel and health care providers responding to that emergency.
• Fundraising: We will contact you for fundraising communications that use your Part 2 information only after providing you a clear and prominent advance notice and obtaining your affirmative permission to do so.

In all circumstances, your Part 2 information will not be used against you in legal proceedings unless you have provided written consent or a court order and subpoena have been issued.

YOUR RIGHTS

When it comes to your health information, you have the following rights. This section explains those rights and some of our responsibilities to help you exercise them.

Inspect and Copy Your Medical Record:

You have the right to inspect and obtain a copy of your paper or electronic medical record and other health information we hold about you. We will provide a copy or summary within 30 days of your request and may charge a reasonable, cost-based fee. Certain records are excluded under federal law, such as psychotherapy notes and information compiled in anticipation of legal proceedings.

Request a Correction:

You may ask us to correct health information you believe is incorrect or incomplete. We may say "no" to your request, but we will tell you why in writing within 60 days. You have the right to submit a statement of disagreement, and we may prepare a rebuttal, a copy of which will be provided to you.

Request Confidential Communications:

You may ask us to contact you by a specific means or at a specific location (for example, home, office, or cell phone). We will honor all reasonable requests.

Ask Us to Limit What We Use or Share:

You may ask us not to use or share certain health information for treatment, payment, or operations. We are not required to agree, but if we do, we will honor that agreement except in a medical emergency. If you pay for a service entirely out-of-pocket, you may request that we not share that information with your health insurer for payment or operations purposes, and we will comply unless the law requires otherwise.

Accounting of Disclosures:

You may request a list of the disclosures we have made of your protected health information for up to six years prior to your request, excluding disclosures for treatment, payment, operations, and certain other categories. We will provide one accounting per year at no charge; additional requests within 12 months may incur a reasonable fee.

Personal Representative:

If someone holds your medical power of attorney or is your legal guardian, that person may exercise your rights and make choices about your health information. We will verify the authority of that person before taking action.

File a Complaint:

If you feel we have violated your rights, you may file a complaint with our Privacy Officer, Marcela Newman DDS MS PA, at the address listed above. You may 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 https://www.hhs.gov/hipaa/filing-a-complaint/index.html. We will not retaliate against you for filing a complaint.

OUR RESPONSIBILITIES

• We are required by law to maintain the privacy and security of your protected health information.
• Breach Notification: We are required to notify you promptly — no later than 60 days after discovery — if a breach occurs that may have compromised the privacy or security of your unsecured protected health information. Notification will describe what happened, what information was involved, what steps you can take to protect yourself, and what we are doing to investigate, mitigate, and prevent future breaches.
• We must follow the duties and privacy practices described in this notice and provide you with a copy of it.
• We will not use or share your information other than as described here unless you authorize us to do so in writing. You may revoke that authorization at any time by notifying us in writing.

CHANGES TO THE TERMS OF THIS NOTICE

We reserve the right to change the terms of this notice at any time, and those changes will apply to all information we hold about you. We will inform you of any material changes. The updated notice will be available upon request, in our office, and on our website.

Effective Date: This notice is effective as of February 16, 2026.

Signature below acknowledges only that you have received this Notice of Privacy Practices.

Print Name: _______________________________   Signature: ____________________

Acknowledgment of Receipt of Notice of Privacy Practices___________   Date: ______________