NOTICE OF PRIVACY PRACTICES

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

Effective Date: July 18, 2026

1. Our Commitment to Your Privacy

Cal American Dental is dedicated to maintaining the privacy of the protected health information (“PHI”) we create and receive about you in the course of providing dental treatment and related services. PHI is information that relates to your past, present, or future physical or mental health condition, the care or services you receive, or payment for that care, and that identifies you or could reasonably be used to identify you. This includes information you provide directly to us, such as through our website’s appointment request form, as well as clinical records, radiographs, treatment notes, and billing information created during your care.

We are required by law to maintain the privacy of your PHI, to provide you with this notice of our legal duties and privacy practices with respect to your PHI, to notify affected individuals following a breach of unsecured PHI, and to abide by the terms of this notice while it is in effect.

2. How We May Use and Disclose Your Health Information

The following categories describe the ways we are permitted to use and disclose PHI without your written authorization. Not every use or disclosure in a category is listed, but all permitted uses and disclosures fall within one of these categories.

2.1 Treatment

We may use and disclose your PHI to provide, coordinate, or manage your dental care and any related services. For example, we may share information with a specialist, oral surgeon, laboratory, or another treating provider involved in your care, or with a prior dentist to obtain your dental history.

2.2 Payment

We may use and disclose your PHI so that treatment and services you receive may be billed to and payment collected from you, an insurance company, or a third party. We currently accept the following insurance carriers, both in-network and out-of-network: Delta Dental, Anthem, Cigna, Aetna, UnitedHealthcare, MetLife, and Guardian.

2.3 Health Care Operations

We may use and disclose your PHI for our operations, which are necessary to run our practice and ensure our patients receive quality care. Examples include quality assessment and improvement activities, staff training, licensing, business planning, and audits.

2.4 Appointment Reminders and Treatment Alternatives

We do not currently offer online appointment scheduling through our website. Patients schedule appointments by contacting our office directly by telephone.

2.5 Individuals Involved in Your Care

We may release information to a family member, friend, or other person you identify who is involved in your dental care or payment for care, or, in the event of your incapacity or an emergency, if we determine that a disclosure is in your best interest.

2.6 As Required by Law

We will disclose PHI when required to do so by federal, state, or local law, including in response to a valid court order or subpoena.

2.7 Public Health Activities and Mandatory Reporting

We may report information to public health authorities as required by law. As health care providers, we are also mandated reporters under California’s Child Abuse and Neglect Reporting Act (Penal Code sections 11165.7 and 11166). If we have a reasonable suspicion that a patient, including a minor, is a victim of abuse or neglect, we are legally required to report this to the ppropriate law enforcement or child welfare agency, even without consent.

2.8 Health Oversight Activities

We may disclose PHI to state or federal agencies for audits, investigations, licensure actions, or inspections, such as the California Dental Board.

2.9 Judicial and Administrative Proceedings

We may disclose PHI in response to a court order, subpoena, or discovery request, subject to certain legal safeguards.

2.10 Law Enforcement

We may disclose limited PHI to law enforcement under specific circumstances, such as reporting a gunshot or knife wound, or in response to a warrant.

2.11 To Avert a Serious Threat to Health or Safety

We may disclose PHI if necessary to prevent a serious threat to your health or safety, or the health or safety of the public.

2.12 Workers’ Compensation

We may disclose PHI as authorized by, or to comply with, workers’ compensation laws.

2.13 Coroners, Medical Examiners, and Funeral Directors

We may disclose PHI to identify a deceased person, determine cause of death, or as needed for funeral directors to carry out their duties.

2.14 Organ and Tissue Donation

If you are an organ donor, we may disclose PHI to organizations that handle organ procurement or transplantation.

2.15 Research

Cal American Dental does not currently participate in research studies involving patient health information. If this changes in the future, any such use would follow applicable federal and state privacy protections, including review by an Institutional Review Board or Privacy Board where required.

2.16 Military, National Security, and Protective Services

If applicable, we may disclose PHI as required by military command authorities or for national security and intelligence purposes.

2.17 Business Associates

We may share PHI with outside companies that perform services on our behalf, such as our billing service, website host, or IT support, under a written contract requiring them to protect your information. Our website does not include any forms or features that collect or transmit patient information.

2.18 Decedents

If a patient is deceased, we may disclose PHI to a coroner, medical examiner, funeral director, or to family members or others involved in the decedent’s care or payment prior to death, unless doing so is inconsistent with any known prior expressed preference of the individual.

3. Uses and Disclosures That Require Your Written Authorization

Except for the uses and disclosures described above, we will not use or share your PHI without your written authorization. This specifically includes marketing communications that involve financial payment to us from a third party, and any sale of your PHI to a third party. You may revoke a written authorization at any time by submitting a written revocation to our Privacy Officer, except to the extent we have already relied on it.

4. Your Rights Regarding Your Health Information

You have the following rights with respect to your PHI. To exercise any of these rights, please submit a written request to our office using the contact information at the end of this notice.

4.1 Right to Inspect and Copy

You may request to inspect and obtain a copy of PHI we maintain about you, such as your dental and billing records, with limited exceptions. Under California law (Health and Safety Code section 123110), we may charge a reasonable fee to cover the cost of copying, capped at $0.25 per page ($0.50 per page for records copied from microfilm), plus reasonable clerical costs actually incurred in preparing the records. We will provide copies within 15 days of a written request, and we will not withhold your records because of an unpaid balance.

4.2 Right to Request Amendment

You may ask us to amend PHI you believe is incorrect or incomplete. We may deny your request under certain circumstances, and if we do, we will explain the reason in writing.

4.3 Right to an Accounting of Disclosures

You may request a list of certain disclosures of your PHI we have made, other than disclosures for treatment, payment, health care operations, and certain other excepted disclosures.

4.4 Right to Request Restrictions

You may ask us to restrict how we use or disclose your PHI for treatment, payment, or health care operations, or to restrict disclosures to individuals involved in your care. We are not required to agree, except that we must agree to a restriction on disclosure to a health plan if the disclosure is for payment or health care operations, is not otherwise required by law, and relates to services you paid for out-of-pocket in full.

4.5 Right to Request Confidential Communications

You may ask us to communicate with you about your health information by an alternative means or at an alternative location.

4.6 Right to a Paper Copy of This Notice

You may request a paper copy of this notice at any time, even if you agreed to receive it electronically.

4.7 Right to Notification of a Breach

You will receive notification if a breach of your unsecured PHI occurs.

4.8 Right to Choose Someone to Act on Your Behalf

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your PHI.

4.9 Minors

For patients under 18, a parent or legal guardian generally must provide consent for treatment and may exercise the rights described in this notice on the minor’s behalf. Under California law (Family Code section 6922), a minor may consent to their own dental care only if the minor is 15 years of age or older, living apart from a parent or guardian, and managing their own finances. Even in that case, the treating dentist may still inform a parent or guardian of care given or needed if their whereabouts are known.

5. Our Duties

– We are required by law to maintain the privacy and security of your PHI.

– We will let you know promptly if a breach occurs that may have compromised the privacy or security of your PHI.

– We must follow the terms of this notice currently in effect.

– We will not use or share your PHI other than as described here unless you provide written authorization, and you may revoke that authorization at any time as described above.

6. Changes to This Notice

We reserve the right to change the terms of this notice and to make the revised notice apply to all PHI we maintain, including PHI created or received before the revision. If we make a material change to our privacy practices, we will promptly revise this notice and make the updated notice available upon request, post it prominently at 1355 S. Garey Ave., Pomona, CA 91766, and post it on our website.

7. Complaints

If you believe your privacy rights have been violated, you may file a complaint with our Privacy Officer at the address, phone number, or email listed below, or with the U.S. Department of Health and Human Services, Office for Civil Rights. You will not be penalized or retaliated against in any way for filing a complaint.

To file a complaint with the Department of Health and Human Services: Online at

www.hhs.gov/ocr/complaints; by mail to the Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201; or by phone at 1-800-368-1019 (TDD: 1-800-537-7697).

8. Contact Information / Privacy Officer

If you have questions about this notice or would like to exercise any of your rights, please contact:

Cal American Dental, Privacy Officer: Dr. Ricardo Jara 1355 S. Garey Ave., Pomona, CA 91766

Phone: (909) 620-4600

Email: calamericandental@gmail.com

A copy of this Notice of Privacy Practices is available at our office, at 1355 S. Garey Ave.,

Pomona, CA 91766, and on our website. This notice was last revised on July 18, 2026.