Luis Martines, DDS, MSD, Inc.
Larchmont Village Orthodontics

321 N. Larchmont Blvd., suite 405, Los Angeles, CA 90004

Tel: (323) 465-7100   Fax: (323) 465-7200   info@larchmontortho.com

Notice of Privacy Practices (effective May 20, 2008)

The Health Insurance Portability and Accountability Act (HIPPA) requires that we maintain the privacy of your health information and have your written consent on issues pertaining to your right of privacy. This notice describes how medical information about you may be used and disclosed. Please review it carefully.

I. Uses and Disclosures

  • Treatment:Your health information may be used or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions and providing treatment.
  • Payment:Your health information may be used to seek payment from your health plan, from other sources of coverage and from credit card companies that you may use to pay for services
  • Health care operations:Your health information may be used as necessary to support the day-to-day activities and management of Luis Martines, DDS, MSD, Inc
  • Law enforcement:Your health information may be disclosed to law enforcement agencies to support government audits and inspections, and to comply with government mandated reporting.
  • Public health reporting:Your health information may be disclosed to public health agencies as required by law.

Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing use or disclosure of your information you may submit a written revocation of authorization. That, however, will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke your previous authorization.

II. Individual Rights

You have certain rights under the federal privacy standards. These include the right to:

  • Request restriction on the use and disclosures of your protected health information.
  • Receive confidential communications concerning your medical condition and treatment.
  • Inspect and copy your protected health information.
  • Amend or submit corrections to your protected health information.
  • Receive an accounting of how/to whom your protected health information has been disclosed.
  • Receive a printed copy of this notice.
  • View the HIPPA laws at www.hippa.com.

III. Request to Inspect Protected Health Information

You may generally inspect or copy the protected health information that we maintain. As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. Also, if you would like to submit a comment about our privacy practices, or if you believe that your privacy rights have been violated, you can do so by sending a letter outlining your concerns to:

Ann Martines, 321 N. Larchmont Blvd., Suite 405, Los Angeles, CA 90004

Acknowledgment of Receipt of Notice of Privacy Practice

I have reviewed and I am in agreement with this office’s HIPPA information

Signature of Patient or Responsible Party