To Our Patients:

This notice describes how health information about you (as a patient of this practice) may be used and disclosed, and
how you can get access to your health information. This is required by the Privacy regulations created as a result of the
health insurance Portability and Accountability Act of 1996 (HIPAA)

Our Commitment To Your Privacy

  • Our practice is dedicated to maintaining the privacy of your health information.
  • We are required by law to maintain the confidentiality of your health information.

We realize that these laws are complicated, but we must provide you with the following important information:

Use and Discloser of Your Health Information in Certain Special Circumstances

  1. To public health authorities and health oversight agencies that are authorized by law to collect information.
  2. Lawsuits and similar proceedings in response to a court or administrative order.
  3. If required to do so by a law enforcement Official.
  4. When necessary to reduce or prevent a serious threat to your health and safety of another individual or the
    public. We will only make disclosures to a person or organization able to help prevent the threat.
  5. If you are a member of U.S. or foreign forces (including veterans) and if required by the appropriate
  6. To federal officials for intelligence and national security activities authorized by law.
  7. To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law
    enforcement official.
  8. For Workers Compensation and similar programs.

Your Right Regarding Your Health Information

  1. Communications. You can request that our practice communicate with you about health and related issues in a
    particular manner or at a certain location. For instance, you may ask that we contact your home, rather than
    work. This may include contacting you by way of non-secured devices, such as answering machines, cellular
    phones, pagers, etc. We will accommodate reasonable requests.
  2. You can request a restriction in our use of disclosure of your health information for treatment, payment or
    health care operations. Additionally, you have the right to request that we restrict our disclosure of your
    information only to certain individuals in our care, such as family members and friends. If we do agree to your
    request, we are bound by agreement except when otherwise requested by law, in emergencies, or when the
    information is necessary to treat you.
  3. You have the right to inspect and obtain a copy of the health information that may be used to make decisions
    about you, including patient medical records and billing records, but not including therapy notes. You must
    submit your request in writing to Couch & Hammond Dentistry Partnership. You must provide us with a reason
    that supports your request for amendment.
  4. Right to a copy of this notice. You are entitled to receive a copy of this notice of Privacy Practices. You may
    ask us to give you a copy of this Notice at any time. To obtain a copy of this notice, contact our front desk
  5. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with
    our practice or with the secretary of the Department of Health and Human Services. To file a complaint with
    our practice, contact Couch & Hammond Dentistry Partnership.
  6. Right to provide authorization for other uses and disclosures. Our practice will obtain your written authorization
    for uses and disclosures that are not identified by this notice or permitted by applicable law.

If you have any questions regarding this notice or our health information privacy policies, please contact Couch & Hammond Dentistry Partnership

970 Camerado Drive Suite 100
Cameron Park, CA 95682
(530)677-0723 * FX (530)677-0366

260 Palladio Parkway #1001
Folsom, CA 95630
(916)805-5077 * FX (916)293-8215