You may download a PDF version of Petaluma Kids Dental Care Notice of Privacy Practices HERE.

I. Dental Practice Covered by this Notice

This notice describes the privacy practices of Petaluma Kids Dental Care. “We” and “our” means the Dental Practice. “You” and “your” means our patient. You may request a copy of our Notice at any time.

II. How to Contact Us/Our Privacy Official

If you have any questions or would like further information about this notice, you can contact Petaluma Kids Dental Care Privacy Official at:

Petaluma Kids Dental Care
Donna Lind
301 Washington St., Ste B
Petaluma, CA 94952
707-762-5149 (fax)

III. Our Legal Obligation

The privacy of your health information is important to us. We understand that your health information is personal and we are committed to protecting it. This notice describes how we may use and disclose your protected health information to carry out treatment, payment, or health care operations, and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected heath information. Protected health information is 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.
We are required by law to:

  • Maintain the privacy of your protected health information;
  • Give you this notice of our legal duties and privacy practices with respect to that information; and
  • Abide by the terms of our Notice that is currently in effect.

IV. Last Revision Date

This Notice was last revised on January 1, 2017

V. How We May Use Or Disclose Your Health Information

1. Treatment. We may use and disclose Health Information for your treatment and to provide you with treatment-related health care services. For example, we may disclose Health Information to doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care.

2. Payment. We may use and disclose Health Information so that we or others may bill and receive payment from you, an insurance company or a third party for the treatment and services you received. For example, we may give your health plan information so that they will pay for your treatment.

3. Health Care Operations. We may use and disclose health information about you in connection with health care operations necessary to run our practice, including review of our treatment and services, training, evaluating the performance of our staff and health care professional, quality assurance, financial or billing audits, legal matters, and business planning and development.

4. Appointment Reminders. We may use or disclose your health information when contacting you to remind you of a dental appointment. We may contact you by using a postcard, letter, phone call, voice message, text or e-mail.

5. Family Members and Friends. We may disclose your health information to a family member or friend who is involved with your care or payment for your care if you do not object or, if you are not present, we believe it is in your best interest to do so.

6. Business Associates. We may disclose your protected health information to our third-party service providers (called, “business associates”) that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use a business associate to assist us in maintaining our practice management software. All of our business associates are obligated, under contract with us, to protect the privacy of your information and not allowed to use or disclose any information and are not allowed to use or disclose any information other than as specified in our contract.

7. Required by Law. We may use or disclose patient health information to the extent we are required by law to do so. For example, we are required to disclose patient health information to the U.S. Department of Health and Human Services so that it can investigate complaints or determine our compliance with HIPAA.

8. Victims of Abuse, Neglect, or Domestic Violence. We may disclose health information to the appropriate government authority about a patient whom we believe is a victim of abuse, neglect, or domestic violence.

9. Lawsuits and Legal Actions. We may disclose patient health information in response to (i) a court of administrative order or (ii) a subpoena, discovery request, or other lawful process that is not ordered by a court if efforts have been made to notify the patient or to obtain an order protecting the information requested.

10. Law Enforcement Purposes. We may disclose your health information to a law enforcement official for a law enforcement purposes, such as to identify or locate a suspect, material witness or missing person or to alert law enforcement of a crime.

11. Specialized Government Functions. We may disclose your health information to the military (domestic or foreign) about its members or veterans, for national security and protective services for the President or other heads of State, to the government for security clearance reviews, and to a jail or prison about its inmates.

Your Rights

A. Right to Access and Review
You may request to access and review a copy of your health information. We may deny your request under certain circumstances. You will receive written notice of a denial and can appeal it. We will provide a copy of your health information in a format you request if it is readily producible. If not readily producible, we will provide it in a hard copy format or other format that is mutually agreeable. If your Health information is included in an Electronic Health record, you have the right to obtain a copy of it in an electronic format and to direct us to send it to the person or entity you designate in an electronic format. We may charge a reasonable fee to cover our cost to provide you with copies of your health information.

B. Right to Amend
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. If we agree to your request, we will amend your record(s) and notify you of such. If we deny your request for an amendment, we will provide you with a written explanation of why we denied it and explain your rights.

C. Right to Restrict Use and Disclosure
You may request that we restrict uses of your health information to carry out treatment, payment, or health care operations or to your family member or friend involved in your care or the payment for your care. We may not (and are not required to) agree to your requested restrictions, with one exception: If you pay out of your pocket in full for a service you receive from us and you request that we not submit the claim for this service to your health insurer or health plan for reimbursement we must honor that request.

D. Accounting of Disclosure
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.

E. Alternative Communication
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. We will accommodate all reasonable requests. However, if we are unable to contact you using the ways or locations you have requested we may contact you using the information we have.

F. Right to Notification of a Breach
You will receive notifications of breaches of your unsecured protected health information as required by law.

Our Right to Change Our Privacy Practices and This Notice

We reserve the right to change our privacy practices and the terms of this Notice at any time. Any changes will apply to the health information we have about you or create or receive in the future. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request. The effective date of this Notice is January 1, 2017.

Questions or Complaints

If you have any complaints or feel that your privacy may have been violated, you can file a complaint with us by Contacting our Privacy Official listed above or you may contact the Secretary of the U.S. Department of Health and Human Services, Office for Civil Rights.

Petaluma Kids Dental Care Notice Of Privacy Practices Signature Form – Secure Submittal

  • By my Signature below, I confirm I have read the Petaluma Kids Dental Care Notice of Privacy Practices

    Please sign, date and submit. We ask for your email as a way to contact you if necessary.
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