Lucky Dental PLLC, DBA Legacy Dental of Denton
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.

Effective Date: 02/16/2026

How We May Use and Disclose Your Health Information

We may use and disclose your health information for treatment, payment, and healthcare operations. This includes coordinating care, processing insurance claims, and improving our services.

Special Protection for Substance Use Disorder Records

Records related to substance use disorder treatment are protected under federal law (42 CFR Part 2). These records may not be disclosed without your written consent unless otherwise permitted by law. They cannot be used in legal proceedings without your consent or a court order and cannot be re-disclosed without permission.

Your Rights

You have the right to access your records, request corrections, request restrictions, request confidential communications, and receive an accounting of disclosures.

Our Legal Duties

We are required by law to maintain the privacy of your health information, provide you with this notice,follow the terms of this notice, and notify you in the event of a breach.

Changes to This Notice

We reserve the right to change this notice at any time. Updated versions will be available in our office and on our website.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with our office or with the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint.

Contact Information

Legacy Dental of Denton 

Phone: 940-565-1871

Address: 1300 Fulton St #102, Denton, TX 76201

Privacy Contact: Office Manager

Acknowledgment of Receipt

I acknowledge that I have received a copy of this Notice of Privacy Practices. 

Patient Name:______________________________         

Signature: _____________________________ Date: ___________

Authorization to Share Information

Person/Office: __________________________   

Purpose: ________________________________

Information: ____________________________   Expiration: ___________ 

Signature:_____________________________     Date: ___________