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.

Your rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get a copy of your health and dental records

You can ask to see or get an electronic or paper copy of your records, including x-rays and other information we have about you. Ask us how to do this. We will provide a copy or a summary, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your records

You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say “no” to your request, but we will tell you why in writing within 60 days.

Request confidential communications

You can ask us to contact you in a specific way (for example, by home or cell phone) or to send mail to a different address. We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

You can ask us not to use or share certain health information for treatment, payment or our operations. We are not required to agree, and we may say “no” if it would affect your care. If you pay for a service or item out of pocket in full, you can ask us not to share that information with your health insurer for payment or our operations. We will say “yes” unless a law requires us to share it.

Get a list of those with whom we’ve shared information

You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why. We will include all disclosures except those about treatment, payment and health care operations, and certain other disclosures (such as any you asked us to make). We will provide one accounting a year for free but may charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive it electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

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 health information. We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

You can complain if you feel we have violated your rights by contacting our HIPAA Compliance Officer using the information at the end of this notice. You can also file a complaint 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/. We will not retaliate against you for filing a complaint.

Your choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends or others involved in your care
• Share information in a disaster relief situation

If you are not able to tell us your preference, for example if you are unconscious or under sedation, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes
• Sale of your information

We do not use your information for fundraising.

Our uses and disclosures

We typically use or share your health information in the following ways.

Treat you

We can use your health information and share it with other professionals who are treating you. Example: after your treatment, we send a report and your x-rays to your general dentist, who will place your permanent restoration.

Run our practice

We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: we use your information to send appointment reminders and to manage your treatment and follow-up visits.

Bill for your services

We can use and share your health information to bill and get payment from dental and health plans or other entities. Example: we give information about you to your dental insurance plan so it will pay for your services.

We are allowed or required to share your information in other ways, usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information, see www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

We can share health information about you for certain situations such as preventing disease, helping with product recalls, reporting adverse reactions to medications, reporting suspected abuse, neglect or domestic violence, and preventing or reducing a serious threat to anyone’s health or safety.

Do research

We can use or share your information for health research, as allowed by law. When we use cases for teaching or publication, we remove information that identifies you.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner or funeral director when an individual dies. Dental records may be used for identification.

Address workers’ compensation, law enforcement and other government requests

We can use or share health information about you for workers’ compensation claims, for law enforcement purposes or with a law enforcement official, with health oversight agencies for activities authorized by law, and for special government functions such as military, national security and presidential protective services.

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Substance use disorder treatment records

If we receive or keep records about you from a substance use disorder treatment program that are protected by federal law (42 C.F.R. Part 2), we will not use or share those records, or testimony about their content, in any civil, criminal, administrative or legislative proceeding against you unless you give us written consent, or a court order is issued and accompanied by a subpoena or other legal requirement compelling disclosure, as federal law allows. Records shared with us under your written consent for treatment, payment or health care operations may be used and shared as described in this notice, except in those proceedings.

Our responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information, see www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Changes to the terms of this notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available on request, in our office and on our website.

Contact us

If you have questions about this notice or want to use any of your rights, please contact our HIPAA Compliance Officer:

HIPAA Compliance Officer
Cottonwood Endodontics, P.C.
4252 S. Highland Drive, Suite 100
Salt Lake City, UT 84124
801-278-3636

Effective date: October 2026. This notice applies to Cottonwood Endodontics, P.C. and Roger K. Warren, DDS.