HIPAA Notice of Privacy Practices

Last Updated: January 28, 2026

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

Who to Contact

If you have questions about this Notice, want to exercise your rights, or want to file a complaint, contact:

Privacy Officer: [Name/Title]

Phone: 214-941-0039

Email: info@championshipdental.com

Mailing Address: 1018 N Zang Blvd, Suite 150, Dallas, TX 75208

Our Responsibilities

We are required by law to:

• Maintain the privacy and security of your protected health information (“PHI”).

• Provide you with this Notice of our legal duties and privacy practices.

• Follow the terms of the Notice currently in effect.

• Notify you following a breach that may have compromised the privacy or security of your information.

How We May Use and Disclose Your PHI Without Your Written Authorization

Federal law allows us to use and disclose your PHI for certain purposes related to your care and our operations, including the following:

1) Treatment

We may use and disclose your PHI to provide, coordinate, or manage your dental care and related services. We may share your PHI with other providers involved in your care (including physicians, specialists, labs, pharmacies, and other health care professionals).

Example: Sharing dental X-rays with a specialist for consultation.

2) Payment

We may use and disclose your PHI to bill and obtain payment from health plans or other responsible parties.

Example: Submitting claims to your dental insurance plan and responding to requests for coverage information.

3) Health Care Operations

We may use and disclose your PHI for practice operations, quality improvement, training, licensing, and administrative activities necessary to run our practice.

Example: Reviewing the quality of care provided or training team members.

4) Appointment Reminders and Practice Communications

We may contact you to remind you about appointments, provide information about treatment alternatives, or communicate about dental services that may benefit you. We may contact you by phone, text message, email, or mail, based on your preferences and the contact information you provide.

5) Business Associates

We may disclose PHI to vendors that help us operate our practice, such as billing services, IT support, software vendors, and electronic health record providers. These vendors are called business associates and are required by law to safeguard your PHI and use it only as permitted by contract and applicable law.

6) As Required by Law / Public Health and Safety

We may use or disclose your PHI when required by law and for certain public purposes, including:

• Public health activities (as required by law)

• Reporting abuse, neglect, or domestic violence (as permitted/required)

• Health oversight activities (e.g., audits, inspections, investigations)

• Law enforcement requests (in limited circumstances)

• Court or administrative proceedings (as permitted/required)

• Coroners, medical examiners, and funeral directors (as permitted)

• Organ donation (as applicable)

• Preventing or reducing a serious threat to health or safety (as permitted)

• Workers’ compensation claims (as permitted)

Uses and Disclosures Requiring Your Written Authorization

We will obtain your written authorization before using or disclosing your PHI for purposes not described in this Notice, unless otherwise permitted or required by law.

We also will obtain your written authorization for:

• Marketing (when HIPAA requires it)

• Sale of PHI (where applicable)

• Most uses and disclosures of psychotherapy notes (if applicable)

You may revoke an authorization at any time in writing, except to the extent we have already acted on it.

Substance Use Disorder (SUD) Records

Special Privacy Protections (42 CFR Part 2)

Some health information related to substance use disorder (SUD) diagnosis, treatment, or referral may be protected by federal law (42 CFR Part 2) and may receive additional confidentiality protections.

Important information about SUD-related records may include:

• In many situations, certain SUD-related records may not be used or disclosed for treatment, payment, or health care operations without your written consent, except as permitted by law.

• These records generally may not be used or disclosed in civil, criminal, administrative, or legislative proceedings against you without your written consent or a court order with specific protections.

• If state or federal laws provide greater privacy protections than HIPAA, we will follow the stricter requirements.

Note: Championship Dental is not necessarily a “Part 2 program.” However, we may receive or maintain SUD-related information as part of your medical or dental history or care coordination, and we will safeguard it as required by applicable law.

Redisclosure Notice

If we disclose your health information as permitted by law, the recipient may re-disclose that information, and it may no longer be protected by HIPAA. Some recipients may be subject to other privacy laws or agreements that continue to protect the information.

Your Rights

You have the following rights regarding your PHI:

Get an electronic or paper copy of your record

You can ask to see or get a copy of your health record and other PHI we have about you. We will provide a copy or a summary, usually within 30 days. We may charge a reasonable, cost-based fee.

Ask us to correct your record

You can ask us to correct PHI you believe is incorrect or incomplete. We may deny your request, but we will explain why in writing.

Request confidential communications

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

Ask us to limit what we use or share

You can ask us not to use or share certain PHI for treatment, payment, or operations. We are not required to agree to all requests. If we agree, we will follow it.

Out-of-pocket restriction: If you pay for a service or item in full out-of-pocket, you can ask us not to share information about that service with your health plan. We will comply unless a law requires us to share it.

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

You can ask for an accounting of certain disclosures we have made in the past six years, with some exceptions.

Get a copy of this Notice

You can ask for a paper copy of this Notice at any time, even if you have agreed to receive it electronically.

Choose someone to act for you

If you have a legal guardian, power of attorney, or other authorized representative, that person can exercise your rights and make choices about your PHI after we verify their authority.

File a complaint if you feel your rights are violated

You can complain if you feel we have violated your rights by contacting our Privacy Officer listed above.

You may also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights (OCR). We will not retaliate against you for filing a complaint.

Fundraising (If Applicable)

We may contact you for fundraising efforts. You have the right to opt out of fundraising communications at any time. To opt out, contact info@championshipdental.com or follow the instructions included in the message.

Changes to This Notice

We may change this Notice, and the changes will apply to all PHI we maintain. The updated Notice will be available in our office and on our website at www.championshipdental.com.

Download PDF  & Archived Versions

Current: Download Notice of Privacy Practices PDF

Archived Versions:
No current archived versions