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Page Mansourian, D.D.S.
NOTICE OF PRIVACY PRACTICES

‍Pezhman Mansourian, Inc.
4015 Mission Oaks Blvd., Suite A, Camarillo, CA 93012
Phone: (805) 987-2701
Website: www.smilebydrm.com
Email: frontoffice@smilebydrm.com
Effective Date: February 18, 2026

THIS NOTICE DESCRIBES HOW HEALTHINFORMATION ABOUT YOU MAY BE USED AND SHARED AND HOW YOU CAN GET ACCESS TO THISINFORMATION. PLEASE REVIEW IT CAREFULLY.

YOUR RIGHTS

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

How to submit requests: Submit requests in writing to Krista Banales, Office Manager, by mail or email (see “Privacy Contact” at the end of this Notice).

GET AN ELECTRONIC OR PAPER COPY OFYOUR DENTAL RECORD

  • You can ask to see or get an electronic or paper copy of your dental record and other health information we have about you.
  • Ask us how to do this. We will provide a copy or a summary, usually within 30 days. We may charge a reasonable, cost-based fee.
    To request: submit in writing (see “How to submit requests” above).

ASK US TO CORRECT YOUR DENTAL RECORD

  • You can ask us to correct health information about you that you think is incorrect or incomplete.
  • We may say “no” to your request, but we’ll explain why in writing.
    To request: submit in writing (see “How to submit requests” above).

REQUEST CONFIDENTIAL COMMUNICATIONS

  • You can ask us to contact you in a specific way (for example, home vs. work phone) or to send mail to a different address.
  • We will say "yes” to reasonable requests.
    To request: Submit requests in writing to Krista Banales at the mailing or email address above.
  • Ask us to limit what we use or share
  • You can ask us not to use or share certain health information for treatment, payment, or our operations.
  • We are not required to agree, and if we do agree, we will follow that agreement.
  • You can ask us not to share information with your health plan for a service you paid for in full out-of-pocket. We will say “yes” unless a law requires us to share that information.
    To request: submit in writing (see “How to submit requests” above).

GET A LIST OF THOSE WITH WHOM WE’VESHARED INFORMATION

  • You can ask for a list (accounting) of times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
  • We will include all disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make).
  • We will provide one accounting a year for free but may charge a reasonable, cost-based fee if you ask for another within 12 months.
    To request: Submit requests in writing to Krista Banales at the mailing or email address above.

GET A COPY OF THIS PRIVACY NOTICE

  • You can ask for a paper copy of this notice at any time, even if you agreed to receive the notice electronically.

CHOOSE SOMEONE TO ACT FOR YOU

  • If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your information.
  • We will verify that this person has authority and can act for you before we take any action.

FILE A COMPLAINT IF YOU FEEL YOURRIGHTS ARE VIOLATED

You can complain if you believe we violated your privacy rights by contacting us using the information below. You can also file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you for filing a complaint.

YOUR CHOICES

For certain health information, you can tell us your choices about what we share. If you have a clear preference, tell us.

IN THESE SITUATIONS, YOU HAVE BOTH THERIGHT AND CHOICE TO TELL US TO:

  • Share information with your family, close friends, or others involved in your care
  • Share information in a disaster relief situation

If you are not able to tell us your preference (for example, you are unconscious), we may share your information if we believe it is in your bestinterest and consistent with applicable law.

IN THESE SITUATIONS, WE WILL NEVERSHARE YOUR INFORMATION UNLESS YOU GIVE US WRITTEN PERMISSION:

  • Marketing purposes
  • Sale of your information

OUR USES AND DISCLOSURES

We typically use or share your health information in the following ways.

TO TREAT YOU

We can use your health information and share it with other professionals who are treating you.
Example: We may share X-rays or treatment information with a specialist you are referred to.

TO RUN OUR OFFICE

We can use and share your health information to run our practice, improve care, and contact you when necessary.
Example: We use information to manage schedules, improve quality, and train staff.

TO BILL FOR SERVICES

We can use and share your health information to bill and get payment from health plans or other entities.
Example: We submit claims to your dental plan and provide information needed for coverage decisions.

APPOINTMENT REMINDERS ANDHEALTH-RELATED BENEFITS/SERVICES

We may contact you to remind you of an appointment, notify you about treatment follow-up, or provide information about dental-related products or services that may benefit you.
How we may contact you: phone, voicemail, text message, email, and mail.
You may request confidential communications as described above.

HOW ELSE CAN WE USE OR SHARE YOURHEALTH INFORMATION?

We are allowed or required to share your information in other ways—usually to help with public health and safety, comply with the law, or address safety concerns. We will meet the conditions in the law before we share your information.

HELP WITH PUBLIC HEALTH AND SAFETYISSUES

We can share information about you for certain situations such as:

  • Preventing disease
  • Helping with product recalls
  • Reporting adverse reactions to medications
  • Reporting suspected abuse, neglect, or domestic violence
  • Preventing or reducing a serious threat to anyone’s health or safety

COMPLY WITH THE LAW

We will share information about you if state or federal laws require it,i ncluding with the U.S. Department of Health and Human Services if it wants to see that we are complying with federal privacy law.

WORK WITH A MEDICAL EXAMINER ORFUNERAL DIRECTOR

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

ADDRESS WORKERS’ COMPENSATION, LAWENFORCEMENT, AND OTHER GOVERNMENT REQUESTS

We can use or share health information about you:

  • For workers’ compensation claims
  • For law enforcement purposes or with a law enforcement official
  • With health oversight agencies for activities authorized by law
  • For special government functions such as military, national security, and presidential protective services

RESPOND TO LAWSUITS AND LEGAL ACTIONS

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Important Part 2 / SUD record protection:
To the extent that we have your substance use disorder patient records that are subject to 42 CFR Part 2, we will not share that information for investigations or legal proceedings against you without (1) your written consent or (2) a court order and a subpoena.

OUR RESPONSIBILITIES

  • We are required by law to maintain the privacy and security of your protected health information.
  • We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
  • We must follow the duties and privacy practices described in this notice and give you a copy of it.
  • We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time in writing.

CHANGES TO THE TERMS OF THIS NOTICE

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.

Website: www.smilebydrm.com

PRIVACY CONTACT

Privacy Contact: Krista Banales, Office Manager
Phone: (805) 987-2701
Email: frontoffice@smilebydrm.com
Mailing Address: 4015 Mission Oaks Blvd., Suite A, Camarillo, CA 93012

 

ACKNOWLEDGMENT OFRECEIPT

We will ask you to sign an acknowledgment that you received this Notice of Privacy Practices. If you choose not to sign, we will document our good-faith effort to obtain your acknowledgment.

 

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