Notice of Privacy Practices

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.

[COUNSEL: this is a placeholder. The final Notice of Privacy Practices must follow 45 CFR § 164.520 and applicable state law. Confirm required header language verbatim.]

1. Our commitment to your health information

Dion Health is committed to protecting the privacy of your protected health information (PHI). We are required by law to maintain the privacy of your PHI, provide you with this notice of our legal duties and privacy practices, and abide by the terms of the notice currently in effect. [PLACEHOLDER]

2. How we may use and disclose your information

We may use and disclose your PHI for the following purposes, subject to applicable limits and consents:

• — Treatment [PLACEHOLDER — example]
• — Payment [PLACEHOLDER — example]
• — Health care operations [PLACEHOLDER — example]
• — Appointment reminders and treatment alternatives [PLACEHOLDER]
• — As required or permitted by law [PLACEHOLDER]

[COUNSEL: enumerate permitted uses/disclosures and those requiring written authorization, including marketing and any sale of PHI.]

3. Uses and disclosures that require your authorization

Other uses and disclosures of your PHI not described in this notice will be made only with your written authorization. You may revoke an authorization in writing at any time, except to the extent we have already acted in reliance on it. [PLACEHOLDER]

4. Your rights regarding your health information

You have certain rights with respect to your PHI, which may include:

• — The right to inspect and copy your records [PLACEHOLDER]
• — The right to request an amendment [PLACEHOLDER]
• — The right to an accounting of disclosures [PLACEHOLDER]
• — The right to request restrictions on certain uses and disclosures [PLACEHOLDER]
• — The right to request confidential communications [PLACEHOLDER]
• — The right to a paper copy of this notice [PLACEHOLDER]

[COUNSEL: confirm the full list of individual rights and the process for exercising each.]

5. Changes to this notice

We reserve the right to change this notice and to make the revised notice effective for PHI we already have, as well as information we receive in the future. [PLACEHOLDER — describe how revised notices will be made available.]

6. Complaints

If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S. Department of Health and Human Services. You will not be penalized or retaliated against for filing a complaint. [PLACEHOLDER — confirm complaint process and contact details.]

7. Contact & Privacy Officer

For questions about this notice or to exercise your rights, contact our Privacy Officer [PLACEHOLDER — name/title]:

Dion Health
450 Sutter Street, Suite 2433
San Francisco, CA 94108
(415) 599-3237 · smile@dionhealthimplants.com