• NOTICE OF PRIVACY PRACTICES

    Prabhdeep Grewal, DDS, INC.

  • THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED BY CORONA ORAL SURGERY AND IMPLANT CENTER AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

    This Notice describes how we may use and disclose your protected health information to carry out treatment, payment or healthcare operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information.

    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.

    HOW WE MAY USE OR DISCLOSE YOUR HEALTH INFORMATION:

    • Treatment. We may use your health information to provide you with treatment or services.
    • Payment. We may use and disclose your health information to obtain payment for our services.
    • Healthcare Operations. We may use and disclose health information about you in connection with healthcare operations necessary to run our practice.
    • Appointment Reminders. We may use or disclose your health information when contacting you to remind you of an appointment.
    • Disclosure to Family Members and Friends if you do not object or, if you are not present, we believe it is in your best interest to do so.
    • Disclosure to 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.
    • Public Health Activities, as may be required by law for preventing or controlling disease or injury.
    • 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.
    • Health Oversight Activities necessary for the government to provide appropriate oversight.
    • Research. Coroners, Medical Examiners and Funeral Directors to allow them to carry out their duties.
    • Law Enforcement Purposes. We may disclose your health information to law enforcement.
    • Workers’ Compensation. We may disclose your health information to comply with workers’ compensation laws or similar programs that provide benefits for work-related injuries or illness.
    • Other Disclosures Required by Law. We may use or disclose patient health information to the extent we are required by law to do so.

    If a use or disclosure of protected health information described above in this notice is prohibited or materially limited by other laws that apply to use, we intend to meet the requirements of the more stringent law.

    Special Protections for Certain Health Information:

    Certain types of health information are subject to additional privacy protections under federal or state law. This includes, but is not limited to, substance use disorder (SUD) treatment records protected by 42 CFR Part 2, certain mental health information, HIV-related information, and genetic information.

    When applicable, these records generally cannot be used or disclosed without your written authorization or a qualifying court order , except as otherwise permitted by law. Where these laws apply, we will comply with the more stringent privacy requirements.

    Any other uses and disclosures not otherwise authorized by HIPAA or applicable federal or state privacy laws will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization. Information we disclose may be subject to redisclosure by the recipient and may no longer be protected by HIPAA.

    YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION:

    • 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. We may charge a reasonable fee to cover our cost to provide you with copies of your health information.
    • Right to Amend. If you believe that your health information is incorrect or incomplete, you may request that we amend it.
    • Right to Restrict Use and Disclosure. You may request that we restrict uses of your health information.
    • Right to Confidential Communications, Alternative Means and Locations. You may request to receive communications of health information by alternative means or at an alternative location.
    • Right to an Accounting of Disclosures. You have a right to receive an accounting of disclosures of your health information for the six (6) years prior to the date that the accounting is requested except for disclosures to carry out treatment, payment, healthcare operations (and certain other exceptions as provided by HIPAA).
    • Right to a Paper Copy of this Notice. You have the right to a paper copy of this Notice.
    • Right to Receive Notification of a Security Breach. You have the right to be notified if we or one of our business associates become aware of a breach of your health information.

    OUR RIGHT TO CHANGE OUR PRIVACY PRACTICES AND THIS NOTICE: We reserve the right to change the terms of this Notice at any time. Any change will apply to the health information we have about you or create or receive in the future. We will promptly revise the Notice when there is a material change to the uses or disclosures, individual’s rights, our legal duties, or other privacy practices discussed in this Notice. We will post the revised Notice on our website (if applicable) and in our office and will provide a copy of it to you on request. The effective date of this Notice is February 16, 2026 .

    HOW TO MAKE PRIVACY COMPLAINTS: If you have any complaints about your privacy rights or how your health information has been used or disclosed, you may file a complaint with us by contacting our Privacy Official listed on the first page of this Notice. You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you in any way if you choose to file a complaint.

    ACKNOWLEDGMENT OF RECEIPT OF NOTICE: We will ask you to sign an acknowledgment that you received this Notice.

    If you have any questions or would like further information about this Notice, you can contact the Practice Privacy Officer at: Linda@cosicdds.com 

  •  I,       have viewed a copy of this office’s Notice of Privacy Practices.

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  • ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

    **You May Refuse to Sign This Acknowledgement**

  • I,      , have received a copy of this office is Notice of Privacy Practices.

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  • CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION


    Purpose of Consent:  By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operation.

    Notice of Privacy Practices:  You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this consent upon request. We encourage you to read it carefully and completely before signing this consent.

    We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. These changes may apply to any of your protected health information that we maintain.

    Right to Revoke:  You have the right to revoke this consent at any time by giving us written notice of your revocation submitted to the Contact Person listed. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

    I,     , have had full opportunity to read and consider the contents of this consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and healthcare operations.

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  • If this Consent is signed by a personal representative on behalf of the patient, complete the following:

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