You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances. If we agree to your request, we will amend your record(s) and notify you of such. If we deny your request for an amendment, we will provide you with a written explanation of why we denied it and explain your rights.

Right to Notification of a Breach.

You may receive notification of breaches of your unsecured protected health information as required by law.

Electronic Notice.

You may receive a paper copy of this Notice upon request, even if you agreed to receive this Notice electronically on our website or by electronic mail (e-mail).



If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternate means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You may also submit a written complaint to the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information; we will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Privacy Officer: Lanelle Zavala

Telephone: (210) 408-7182 || Fax: (210) 408-7993


Address: 1202 W. Bitters, Bldg. #5, San Antonio, TX 78216

©2012 American Dental Association All Rights Reserved

Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication of this form by any other party requires the prior written approval of the American Dental Association.

This form is educational only, does not constitute legal advice, and covers only federal, not state, law. Changes in application laws or regulations may require revision. Dentists should contact their attorneys for legal advice pertaining to HIPPA compliance, the HITECH Act, and the U.S. Department of Health and Human Services rules and regulations.


Copy Fees Under the Texas Medical Practice Act

The 1995 Texas Legislature directed the then Texas State Board of Medical Examiners to adopt rules interpreting the “reasonable fee” standard in the law and set the maximum charges for release of medical records.

The TMB has adopted rules setting the maximum cost of copies. Under these rules, physicians may charge no more than $25 for the first twenty pages, and 50 cents for each page thereafter, along with a reasonable fee for the actual costs of mailing, shipping or delivery. [1] Thus, a physician may charge a maximum of $ 27.50 for a 25-page chart. No specific retrieval or “pull fee” is allowed in the final rules. Where the request is for films or other static diagnostic imaging studies the practice is entitled to no more than $ 8.00 per copy. These are maximums and the rules bear out that the fee actually charged must be “cost based.”