HIPAA Notice of Privacy Practices

Effective Date: June 18, 2026

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

OUR COMMITMENT TO YOUR PRIVACY

We are required by law to maintain the privacy of your protected health information ("PHI"), to give you this notice of our legal duties and privacy practices regarding your PHI, to notify you if a breach of your unsecured PHI occurs, and to abide by the terms of the notice currently in effect.

We reserve the right to change our privacy practices and the terms of this Notice at any time, including for health information we created or received before we made the changes. Before we make a significant change, we will update this Notice and make it available upon request. The current Notice will always be posted in our office and on our website at socalsmilestustin.com/npp. You may request a copy at any time using the contact information at the end of this Notice.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

Treatment

We may use and share your health information to provide, coordinate, or manage your dental care. For example, we may share your treatment plan with a specialist we refer you to, such as an oral surgeon, endodontist, or orthodontist.

Payment

We may use and share your health information to bill and collect payment for your care. For example, we may send diagnosis and treatment information to your dental insurance plan so that claims can be paid.

Health Care Operations

We may use and share your health information to run our practice, including quality assessment and improvement, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner performance, conducting training programs, and accreditation, certification, licensing, or credentialing activities.

To Your Family and Friends

We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your health care or payment for your health care, but only if you agree in writing that we may do so. If you are present, we will give you the opportunity to object before any such disclosure. In the event of your incapacity or an emergency, we will: (1) disclose health information based on our professional judgment, sharing only what is directly relevant to that person's involvement in your care; and (2) use our professional judgment and experience with common practice to make reasonable inferences about your best interest, including allowing third parties to pick up prescriptions, medical supplies, X-rays, or other similar items.

Your Written Authorization

Other than the situations described in this Notice, we will not use or share your health information without your written authorization. This includes uses for marketing purposes and any sale of your health information. If you give us a written authorization, you may revoke it in writing at any time, except to the extent we have already relied on it.

Other Permitted Uses and Disclosures

We may also use or share your health information without your written authorization, as permitted by law, for the following purposes:

As required by law
For public health activities (such as reporting required by public health authorities)
For health oversight activities (such as audits or inspections)
In judicial or administrative proceedings (such as in response to a court order)
For law enforcement purposes, in limited circumstances
To avert a serious threat to your health or safety or the health or safety of others
For organ and tissue donation purposes
For workers' compensation claims
To coroners, medical examiners, or funeral directors, as necessary
For research, subject to specific privacy safeguards
For appointment reminders, and to tell you about treatment options or other health-related benefits and services that may interest you
With business associates who perform services on our behalf (for example, our online scheduling/patient portal provider or billing service), under a written agreement requiring them to protect your information
With family members, friends, or others involved in your care or payment for your care, unless you object
For lawful military intelligence, counterintelligence, or national security activities
For fundraising activities — you have the right to opt out of these communications at any time

Stricter Protections for Substance Use Disorder (SUD) Records

Some health information — specifically alcohol and/or substance use disorder treatment records governed by 42 CFR Part 2 — is entitled to heightened confidentiality protections:

Use for Treatment, Payment, and Operations: If we receive SUD records through your general consent, we may use them for treatment, payment, and health care operations as described above.
Legal Proceedings: In no event will we use or disclose your SUD records, or testimony describing them, in any civil, criminal, administrative, or legislative proceedings against you without your express written consent or a specific court order.
Redisclosure: SUD records may remain protected from redisclosure under these stricter laws even if other PHI is not.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

To exercise any of the rights below, please contact our Privacy Officer using the information at the end of this Notice.

Right to Access: You have the right to review or obtain copies of your health information, with limited exceptions. You may request copies in a format other than photocopies. You must make your request in writing.
Right to Amend: You have the right to request that we amend your health information if you believe it is incorrect or incomplete. Any such request must be in writing and must explain why the information should be amended. We may deny your request under certain circumstances.
Right to an Accounting of Disclosures: 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, health care operations, and certain other activities, for the last 6 years. We will provide such a list at no charge once in any 12-month period. We reserve the right to charge for requests in excess of one per 12-month period.
Right to Request Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
Right to Confidential Communications: 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, specify the alternative means or location, and provide a satisfactory explanation of how payments will be handled under the alternative you request.
Right to a Paper Copy of This Notice: You have the right to a paper copy of this Notice at any time, even if you agreed to receive it electronically.
Right to Choose a Personal Representative: You have the right to choose someone to act on your behalf regarding your health information.
Right to Notification of a Breach: You have the right to be notified in the event of a breach of your unsecured health information.
Right to File a Complaint: You have the right to file a complaint if you believe your privacy rights have been violated. We will not retaliate against you for filing a complaint with us or with the U.S. Department of Health and Human Services.

HOW TO FILE A COMPLAINT

If you believe your privacy rights have been violated, you may file a complaint with us at the contact information below, or with the U.S. Department of Health and Human Services, Office for Civil Rights:

U.S. Department of Health and Human Services, Office for Civil Rights 200 Independence Avenue, S.W., Washington, D.C. 20201 Phone: 1-800-368-1019 | www.hhs.gov/ocr/privacy/hipaa/complaints

We will not retaliate against you for filing a complaint.

CONTACT US

Privacy Officer: Matthew Moniaga, President Southern California Smiles, a DBA of Moniaga DDS, Inc., A Professional Dental Corporation | 12791 Newport Ave Suite 200, Tustin, CA 92780 | Phone: 714-730-7777 | Website: socalsmilestustin.com/npp

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