Katy Dental Experts
6840 S Mason Rd Suite 600, Katy, TX 77450
832 321 5799
• A statement that this practice is required by law to maintain the privacy of protected health information.
• A statement that this practice is required to abide by the terms of the notice currently in effect.
• Types of uses and disclosures that this practice is permitted to make for each of the following purposes;
treatment, payment, and health care operations.
• A description of each of the other purposes for which this practice is permitted or required to use or disclose
protected health information without my written consent or authorization.
• A description of uses and disclosures that are prohibited or materially limited by law.
• A description of other uses and disclosures that will be made only with my written authorization and that I may
revoke such authorization.
• My individual rights with respect to protected health information and a brief description of how I may exercise
those rights in relation to:
• The right to complain to this practice and to the Secretary of HHS if I believe my privacy rights have been
violated, and that no retaliatory actions will be used against me in the event of such a complaint.
• The right to request restrictions on certain uses and disclosures of my protected health information, and
that this practice is not required to agree to a requested restriction.
• The right to receive confidential communications of protected health information.
• The right to inspect and copy protected health information.
• The right to amend protected health information.
• The right to receive an accounting of disclosures of protected health information.
• The right to obtain a paper copy of the Notice of Privacy Practices from this practice upon request.