HIPAA Statement


Notice of Berkeley Dental Group Privacy Practices

Effective Date: January 27, 2015


The Health Insurance Portability and Accountability Act of 1996
(HIPAA) requires us to ask each of our patients to acknowledge receipt of our Notice of Privacy Practices.


Berkeley Dental Group Responsibilities

Under the Health Insurance Portability and Accountability Act
of 1996 (HIPAA), Berkeley Dental Group must take steps to protect the privacy of your “Protected Health Information” (PHI). PHI includes information that we have created or received regarding your health or payment for your health. It includes both your medical records and personal information such as your name, social security number, address, and phone number.

Under federal law, we are required to:

  • Protect the privacy of your PHI. All of our employees and Doctors are
    required to maintain the confidentiality of PHI and receive appropriate privacy training
  • Provide you with this Notice of Privacy Practices explaining
    our duties and practices regarding your PHI
  • Follow the practices and procedures set forth in the Notice

Uses and Disclosures of Your Protected Health Information That Do Not Require Your Authorization

Berkeley Dental Group uses and discloses PHI in a number of
ways connected to your treatment, payment for your care, and our
health care operations. Some examples of how we may use or
disclose your PHI without your authorization are listed


  • To our Dentists, Hygienists, and others involved in your
    health care or preventive health care.
  • To our different departments to coordinate such activities
    as prescriptions, lab work, and X-rays.
  • To other health care providers treating you who are not on
    our staff such as doctors, emergency room staff, and


  • To administer your health benefits policy or contract.
  • To bill you for health care we provide.
  • To pay others who provided care to you.
  • To other organizations and providers for payment activities
    unless disclosure is prohibited by law.

Health-care Operations

  • To administer and support our business activities or those
    of other health care organizations (as allowed by law) including
    providers and plans. For example, we may use your PHI to review and
    improve the care you receive and to provide training.
  • To other individuals and organizations that help us with our business activities. (Note:If we share your PHI with other organizations for this purpose, they must agree to protect your privacy.)


We may use or disclose your Protected Health Information without your authorization for legal and/or governmental purposes in the following circumstances:

  • Required by law – When we are required to do so by state and
    federal law, including workers’ compensation laws.
  • Public health and safety – To an authorized public health
    authority or individual to:
  • Protect public health and safety.
  • Prevent or control disease, injury, or disability.
  • Investigate or track problems with prescription drugs and medical devices. (Food and Drug Administration.)
  • Abuse or neglect – To government entities authorized to receive reports regarding abuse, neglect, or domestic violence.
  • Oversight agencies – To health oversight agencies for certain activities such as audits, examinations, investigations, inspections, and licensures.
  • Legal proceedings – In the course of any legal proceeding in
    response to an order of a court or administrative agency and, in certain cases, in response to a subpoena, discovery request, or other lawful process.
  • Law enforcement – To law enforcement officials in limited
    circumstances for law enforcement purposes. For example disclosures may be made to identify or locate a suspect, witness, or missing person; to report a crime; or to provide information concerning victims of crimes.
  • Military activity and national security – To the military
    and to authorized federal officials for national security and intelligence purposes or in connection with providing protective services to the President of the United States.

We may also use or disclose your Protected Health Information without your authorization in the following miscellaneous circumstances:

  • Family and friends—To a member of your family, a relative, a close friend—or any other person you identify who is directly involved in your health care—when you are either not present or unable to make a health care decision for yourself and we determine that disclosure is in your best interest.
  • All of this information except religious affiliation will be disclosed to people who ask for you by name. Members of the clergy will be
    told your religious affiliation if they ask. This is to help your family, friends, and clergy visit you in the facility and generally know how you are doing.
  • Treatment alternatives and plan description—To
    communicate with you about treatment services, options, or alternatives, as well as health-related benefits or services that may be of interest to you, or to describe our health plan and providers to you.
  • De-identify information—If information is removed from your PHI so that you can’t be identified, as authorized by law.
  • Coroners, funeral directors, and organ donation—To coroners, funeral directors, and organ donation organizations as authorized by law.
  • Disaster relief—To an authorized public or private entity for disaster relief purposes. For example, we might disclose your PHI to help notify family members of your location or general condition.
  • Threat to health or safety—To avoid a serious threat to the health or safety of yourself and others.
  • Correctional facilities—If you are an inmate in a correctional facility we may disclose your PHI to the correctional facility for certain purposes, such as providing health care to you or protecting your health and safety or that of others.

Uses and Disclosures of Your Protected Health Information That Require Us to Obtain Your Authorization Except in the situations listed in the sections above, we will use and disclose your PHI only with your written authorization. This means we will not use your Protected Health Information in the following cases, unless you give us written permission:

  • Marketing Purposes
  • Sale of your information
  • Most sharing of psychotherapy notes

In some situations, federal and state laws provide special protections for specific kinds of PHI and require authorization from you before we can disclose that specially protected PHI. In these situations, we will contact you for the necessary authorization. In some situations, you may revoke your authorization; instructions regarding how to do so are contained in the form authorization you obtain from us. If you have questions about these laws, please contact our Privacy Officer at (510) 548-5417.

Your Rights Regarding Your Protected Health Information

You have the right to:

  • Request restrictions by asking that we limit the way we use or
    disclose your PHI for treatment, payment, or health care operations. You may also ask that we limit the information we give to someone who is involved in your care, such as a family or friend. Please note that we are not required to agree to your request except when a restriction has been requested regarding a disclosure to a health plan in situations where the patient has paid for services in full and where the purpose of the disclosure is for payment or healthcare operations. If we do agree, we will honor your limits unless it is an emergency situation.
  • Ask that we communicate with you by another means. For example, if you want us to communicate with you at a different address we can usually accommodate that request. We may ask that you make your request to us in writing. We will agree to reasonable requests.
  • Request an electronic or paper copy of your PHI. We may ask you to make this request in writing and we may charge a reasonable fee for the cost of producing and mailing the copies, which you will receive usually within 30 days. In certain situations we may deny your request and will tell you why we are denying it. In some cases you may have the right to ask for a review of our denial.
  • Ask usually to amend PHI about you that we use to make decisions about you. Your request for an amendment must be in writing and
    provide the reason for your request. In certain cases we may deny your request, in writing. You may respond by filing a written statement of disagreement with us and ask that the statement be included with your PHI.
  • Seek an accounting of certain disclosures by asking us for a
    list of the times we have disclosed your PHI. Your request must be in writing and give us the specific information we need in order to respond to your request. You may request disclosures made up to six years before your request. You may receive one list per year at no charge. If you request another list during the same year, we may charge you a reasonable fee. These lists will not include disclosures to other organizations that might pay for your care provided by B.
  • Request a paper copy of this Notice.
  • Receive written notification of any breach of your unsecured PHI.
  • File a complaint if you believe your privacy rights have been violated. You can file a written complaint with us at the address below, or with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints.


By utilizing our services or replying to our emails, you acknowledge that you are aware that email is not a secure method of communication, and that you agree to the risks. If you would prefer not to exchange personal health information via email, please notify us at: office@berkeleydentalgroup.com.

Changes to Privacy Practices

Berkeley Dental Group may change the terms of this Notice at
any time. We will make any such changes to our website.

Questions and Complaints

If you have any questions about this Notice or would like an
additional copy, please contact the Privacy Officer at (510)-548-0570 or by email at: office@berkeleydentalgroup.com.

If you think that we may have violated your privacy rights or you disagree with a decision we made about access to your PHI, you may send a written complaint to the Privacy Officer at Berkeley Dental Group 3000 Colby St # 300, Berkeley, CA 94705