privacy practice

NOTICE OF PRIVACY PRACTICES

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THIS NOTICE DESCRIBES HOW DENTAL INFORMATION ABOUT YOU MAY BE USED AND

DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT

CAREFULLY.

You will be asked to acknowledge that you have received our notice of privacy

practices.

We understand that information about you and your health is very personal and therefore, we will

strive to protect your privacy as required by law. Individually identifiable information about your past,

present or future health or condition, the provision of dental health care to you, or payment for such

dental health care is considered "Protected (Personal) Health Information" ("PHI"). We will only use

and disclose your personal health information as allowed by applicable law.

We are committed to excellence in the provision of state-of-the-art health care services through the

practice of patient care and education. Therefore, as described below, we train our staff and workforce

to be sensitive about privacy and to respect the confidentiality of your personal health information.

We are required by law to maintain the privacy of our patients' personal health information and to

provide patients with notice of our legal duties and privacy practices with respect to your personal

health information. We are required to abide by the terms of this Notice of Privacy Practices so long as

it remains in effect. We reserve the right to change the terms of this Notice of Privacy Practices as

necessary and to make the new Notice of Privacy Practices effective for all personal health information

maintained by us.

Except as outlined below, we will not use or disclose your personal health information for any purpose

unless you have signed a form authorizing the use or disclosure. This form will describe what

information will be disclosed, to whom, for what purpose, and when. You have the right to revoke that

authorization in writing, except to the extent we have already relied upon it.

1. Permitted Uses and Disclosures of Your Protected Health Information

The following categories detail the various ways in which we may use or disclose your personal

health information. For each category of uses or disclosures we will give you illustrative examples.

It should be noted that while not every use or disclosure will be listed, each of the ways we are

permitted to use or disclose information will fall into one of the following categories:

a. Treatment: We may disclose PHI to our dental staff for treatment purposes. For example,

your dentist may wish to provide a dental service to you but first seek information as to

whether the service has been previously provided.

b. Payment: We disclose your PHI in order to fulfill our duty to provide your coverage,

determine your benefits and make payment for services provided to you. For example, we use

your PHI in order to process your insurance claims.

c. Health Care Operations: We disclose your PHI as a part of certain operations, such as

quality improvement. For example, we may use your PHI to evaluate the quality of dental

services that were performed.

We may be asked by the sponsor of your dental health plan to provide your PHI to the

sponsor. If we are asked to do so, we intend to honor such requests unless we are prohibited

by law from doing so.

We may use or disclose your PHI without your authorization for several other reasons. Subject

to certain requirements, we may give out PHI without your authorization for public health

purposes, auditing purposes, research studies and emergencies. We provide PHI when

otherwise required by law, such as for law enforcement in specific circumstances, or for

judicial or administrative proceedings. In any other situation, we will ask for your written

authorization before using or disclosing your PHI. If you choose to sign an authorization to

NOTICE OF PRIVACY PRACTICES

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allow disclosure of your PHI, you can later revoke that authorization to stop any future uses

and disclosures (other than for treatment, payment and health care operations).

d. Appointment Reminders: We may use and disclose dental information to contact you as a

reminder that you have an appointment for treatment or dental care. The reminder may be

by mail, email, text message, or as a telephone message.

e. Treatment Alternatives: We may use and disclose dental information to tell you about or

recommend possible treatment options or alternatives that may be of interest to you.

f. Health-Related Benefits and Services: We may use and disclose dental information to tell

you about health-related benefits or services that may be of interest to you.

g. Individuals Involved in Your Care or Payment for Your Care: We will only disclose

information to a patient's guardian, representative with power of attorney, and to people the

patient invites to physically accompany him or her. Information will be disclosed to this patient

representative in the presence of the patient. In certain emergency situations it may not be

possible to have the patient present, in which case we may, in the exercise of professional

judgment, determine whether the disclosure is in the best interests of the patient, and if so,

disclose only information directly relevant to the person's involvement with the patient's

health care or related payment.

h. Business Associates: Certain aspects and components of our services are performed

through contracts with outside persons or organizations, such as auditing and legal services.

At times it may be necessary for us to provide your personal health information to one or

more of these outside persons or organizations who assist us with our payment/billing

activities and health care operations. In such cases, we require these business associates to

appropriately safeguard the privacy of your information.

2. Individual Rights

In most cases, you have the right to view or get a copy of your PHI. You also have the right to

receive a list of instances where we have disclosed your PHI without your written authorization for

reasons other than treatment, payment or health care operations. If you believe that information

in your record is incorrect or if important information is missing, you have the right to request that

we correct the existing information or add the missing information.

You may request in writing that we not use or disclose your PHI for treatment, payment and

health care operations except when specifically authorized by you, when required by law, or in

emergency circumstances. Although we are unable to take back any disclosures we have already

made with your permission or pursuant to this notice, we will consider your request but are not

legally required to accept it. You also have the right to receive confidential communications of PHI

by alternative means or at alternative locations, if you clearly state that disclosure of all or part of

your PHI could endanger you.

3. Complaints

If you are concerned that we have violated your privacy rights, or you disagree with a decision we

have made about access to your records, you may contact us at our practice address. You may

also send a written complaint to the U.S. Department of Health and Human Services. You will not

be penalized for making a complaint.

NOTICE OF PRIVACY PRACTICES

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4. Our Legal Duty

We are required by law to protect the privacy of your information, provide this notice about our

information practices and follow the information practices that are described in this notice.

We may change our policies at any time. Before we make a significant change in our policies, we

will change our notice and send the new notice to you. We reserve the right to make the revised

or changed notice effective for dental information we already have about you as well as any

information we receive in the future. You can also request a paper copy of our notice at any time

by contacting our dental practice.

If you wish to inspect your records, receive a listing of disclosures, or correct or add to the

information in your record, or if you have any questions, complaints or concerns, please contact

our dental practice.

ACKNOWLEDGEMENT

I have received a copy of the Notice of Privacy Practices. I understand that official privacy practices

may change from time to time and that I may request, at any time, a current copy

of the Notice of Privacy Practices.

Patient Name: ____________________________________________________________

Signature of Patient or Legal Guardian: ______________________________________

Date: ____________________________