PREMIUM DENTISTRY CARE.
ONE YEARLY MEMBERSHIP.
Notice of Privacy Practices
Clarity Dental Club
Effective Date: [Insert Date]
This Notice of Privacy Practices describes how medical information about you may be used and disclosed and how you can access this information. Please review it carefully.
Our Commitment to Your Privacy
Clarity Dental Club (“we,” “our,” or “us”) is committed to protecting the privacy of your protected health information (“PHI”) as required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), applicable federal regulations, and Arizona state law.
• We are required by law to:
• Maintain the privacy of your PHI
• Provide you with this Notice of our legal duties and privacy practices
• Follow the terms of this Notice
How We May Use and Disclose Your Health Information
We may use and disclose your PHI for the following purposes without your written authorization:
1. Treatment
We may use your health information to provide, coordinate, or manage your dental care and related services.
2. Payment
We may use and disclose your PHI to obtain payment for services provided to you, including membership administration and payment processing.
3. Healthcare Operations
We may use your information for operational purposes such as quality assessment, training, licensing, and business management.
Other Permitted Uses and Disclosures
We may also use or disclose your PHI:
• As required by federal, state, or local law
• For public health and safety activities
• To comply with legal proceedings or law enforcement requests
• For health oversight activities
Any other uses or disclosures not described in this Notice will be made only with your written authorization.
Your Rights Regarding Your Health Information
You have the right to:
• Inspect and copy your dental records
• Request amendments to your records
• Request restrictions on certain uses or disclosures
• Request confidential communications
• Receive an accounting of disclosures
• Receive a paper copy of this Notice
To exercise these rights, please contact our office directly.
Website & Electronic Communications
Our website, contact forms, and email communications are not intended for transmitting sensitive medical or personal health information.
Please contact our office directly for matters involving diagnosis, treatment, or emergencies.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with:
Clarity Dental Club
📞 [Phone Number]
or with:
U.S. Department of Health and Human Services
Office for Civil Rights
www.hhs.gov/ocr
You will not be penalized for filing a complaint.
Changes to This Notice
We reserve the right to change this Notice at any time. Any changes will apply to all PHI we maintain and will be posted on our website.
Contact Information
Clarity Dental Club
📍 [Full Physical Address]
📞 [Phone Number]
📧 [email protected]
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