• Patients are required to be on time for their appointments.  If cancellation of your appointment is necessary, 24-hours notice during the Monday through Friday campus week is required to allow your student adequate time to refill the empty appointment time.

• The student's final grade is based on the number of patients completed.  Last minute cancellations and missed appointments can jeopardize the students ability to complete clinical assignments and course requirements.

• A total of TWO cancellations without 24 hours notice, TWO missed appointments, or repeated unsuccessful attempts to arrange for an appointment may be cause to discontinue a patient from further treatment in the Dental Hygiene Clinic.

• You are responsible for non-refundable payment before services are rendered.

• It is your responsibility to select a personal dentist for annual exams, continued care (preventative and restorative), and emergencies.

Privacy Policies and Practices of the Allied Dental Programs

THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE OBTAINED/REVIEWED BY OUR FACULTY AND STUDENTS. PLEASE REVIEW IT CAREFULLY.  

You are a valued participant in our educational program and we are vitally interested in protecting the privacy of our patients. To do so we have developed privacy policies and procedures. This notice describes how we safeguard this data so that your health information will not be compromised while you are a patient in our clinics.  

¨Protected health information¨ is individually identifiable health information transmitted or maintained by electronic or other media.  

We use and disclose only the minimum protected health information to perform services for you. Examples of such use and disclosures are:  

Treatment
We use and disclose health information to treat patients by way of health history forms and consent for treatment forms involving dental hygiene procedures, x-ray procedures, coronal polishing procedures and other clinically obtained and evaluated procedures. We may obtain this data from you directly or from another health care provider. We may disclose this health information to another health care provider or within our educational facility as it pertains to your treatment in the SRJC Dental Clinic.  

Operations
We use and disclose protected health information for activities that are related to the educational requirements of the college, accreditation requirements and related curriculum. This may include calibrating the performance of our health care professionals, conducting training, accreditation, and licensing or credentialing activities.  

Authorization
We may use protected health information for other purposes only if you have authorized us in writing to do so. However, we do not use patient health data in this way and will not ask your authorization to do so.

We limit how, when and where we may disclose protected health information. When we do so, we disclose only the minimum information required. Examples include:

Law
We must disclose protected health information if required by law, a warrant or court order, or to report information about a crime victim.

Public Health
We may disclose protected health information to public health or government oversight agencies as authorized by law.

Safety
We may disclose protected health information to prevent a serious threat to the health and safety of a student or others from taking place.

Government
We may disclose protected health information as required by the military or federal government for national security and intelligence activities.

We protect your rights regarding your offices protected health information. Patients have rights regarding their protected health information. These rights include:

Access
Patients may review and obtain a copy of the protected health information we keep.

Accounting
You may request that we account for any disclosures we have made of protected health information. This request must be in writing and may not be for a period longer than six years and not include dates before April 14, 2016.

Restriction
You may request that we restrict our disclosure of protected health information. However, we are not required to agree to this request if it has an impact on our ADA Commission on Accreditation Guidelines and Standards.

Communications
You may request that we communicate with you about our handling of protected health information in a certain manner, time or place. Your request must be in writing and we will honor all reasonable requests.

Changes to our privacy policies and procedures
We may change the policies and procedures contained in this notice. If we make a material change in our policies and procedures we will provide you with an updated copy of our privacy practices at your request.

How to contact us regarding privacy
If you have any questions about the privacy rights of patients or this notice, complaints about how we have protected the privacy of protected health information obtained by our students, or ideas how to best improve our privacy policies please contact the person listed below. If you believe that we have violated privacy rights you may contact the Secretary of the Department of Health and Human Services.

Contact Person:
Lucinda Fleckner
Director: Allied Dental Education Program
Santa Rosa Junior College
1501 Mendocino Ave. Santa Rosa, CA 95401
(707) 527-4583

HOW TO FILE A HEALTH INFORMATION PRIVACY COMPLAINT WITH THE OFFICE FOR CIVIL RIGHTS:

http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html

Region IX - AZ, CA, HI, NV, AS, GU, The U.S. Affiliated Pacific Island Jurisdictions
Office for Civil Rights
U.S. Department of Health & Human Services
50 United Nations Plaza - Room 322
San Francisco, CA 94102
(415) 437-8310; (415) 437-8311 (TDD)
(415) 437-8329 FAX