€n [.|[date]...intelligence, counterintelligence and other national security activities. We may disclose to correctional institutions or law enforcement omcials having lawful custody

This notice describes how your health information may be used and disclosed and how you €n get access iothis information Please review tt carefully. The privacy of your health information ts tmportant to us.

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feOerat anO state laws require us to maintain the pravacy of your health information. We are also required toprovide this notice about our office's privacy practices, our legal duties and your rights regatding your healthinformation. We are required to follow the practices that are outlined in this notice while it is in effect. Thisnotice takes effectf -23_- [.|[date] and will remain in effect untit we replace it.We reserve the right to change our pnvacy practices and the terms of this notice at any time, provided suchchanges are permitted by applicable law. We reserve the right to make ch:.rge: in our privacy practices andthe new terms of our notice effective for all health informataon that we maintain, including health irrformation wecreated or received before we made the changes. Before we make a significant change in our privacypractices, we will change this notice and make the new notice available upon request. For more informationabout our privacy practices or additional copies of this notice, please contact us (contact information below).

,,1-.r :.1.1 -r.S::1S:":'CS,:.':i-,-:r. .. ,-.,'.:: t.'We use and disclose health information about you for treatment, payment and health care operations.For example:

Tteatment tWe disclose medical information to our employees and others who are involved irr providing the care youneed. We may use or disclose your health information to another dentist or other health care providersproviding treatment that we do not provide. We may also share your health information with a pharmacist inorder to provide you with a prescription or with a laboratory that performs tests or fabricates dental prosthesesor orthodontic appliances.

PaymentWe may use and disclose your health information to obtainrequest that we restrict such disclosure to your health planservices rendered.

payment for services we provide to you, unless youwhen you have paid out-of-pocket and in full for

Health Care OperationsWe may use and disclose your health informataon in connection with our health care operations. Health careoperations include. but are not limited to, quality assessment and improvement activitres, reviewing thecompetence or qualifications of health care professionals, evaluating practitioner and provider performance,conducting training programs, accreditation, ce(ification, ricensing or credentiaring activities.

Your Authorizationln addition tcrour use of your health information for treatment, payment or health care operations, you maygive us written authorization to use your health information or to disclose it to anyone for any orrpoa". tt yo,give us an authorization, you may revoke it in writing at any time. Your revocation wilt noi affect any use ordisclosures permitted by your authorization while it is in effect. unless you give ds a written authorization, wecannot use or disclose your health information for any reason except those described in this notice

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To Your Family and FriendsWe must disclose your health information to you, as described in the Patient Rights section of this notice. youhave the right to request restrictions Gn disclosure to family members, other relatives, close personal iriends orany other person identified by you.

Unsecured EmailsWe will not send you unsecured emails pertaining to your health informatron without your prior authorization. lfyou do authorize communications via unsecured email, you have the right to revoke the authorization at anytime.

Percons lnvolved in CareWe may use or disclose health information to notify, or assist in the notification of (including identitying orlocating) a family member, your personal representative or another person responsible for your care, of yourlocation, your general condition or your death. lf you are present, then prior to use or disclosure of your healthinformation, we will provide you with an opportunity to object to such uses :rr c:sclosures. ln the event of yourincapacity or emergency circumstances, we will disclose health information based on a determination usingour professional judgment disclosing only health information that is direcgy relevant to the person sinvolvement in your health care. We will also use our professional judgment and our experience with commonpractice to make reasonable inferences of your best interest in allowjng a person to pick up filled prescriptions,medical supplies, X-rays or other similar forms of health information.

Marketing Health-RelatedServices'we may contact you about products or services rerated to your treatment, case management or carecoordination or to propose other treatments or health-related benefits and services in which you may l.:einterested. We may also encourage you to purchase a product or service when you visit cur office. lf you arecurrently an enrollee of a dental plan, we may receive payment for communieat;ons to you in relation to ourprovision, coordination or management of your dental care, including our coordination or management of yourhealth care with a third party, our consultation with other health care provide!-s relating to your care or if werefer you for health care. We will not otherwise use or disclose your health information for marketing purposeswithout your written authorization. We will disclose whether we receive payments for marketing activity youhave authorized

Change of Ownershiplf this dental practice is sold or mergeo with another practice or organization, your health records will becomethe property of the new owner. However, you may request that copies of your health information be transferredto another dental practice.

Required by LawWe may use or disclose your health information when we are required to do so by law.

Public HeafthWe may, and are sometlmes legally obligated to, disclose your health information to public health agencaes forpurposes related to preventing or controlling disease, injury or disability, iepr.,,rting abuse or negtect; reportingdomestic violence; reporting to the Food and Drug Administration problems with products and reactions tomedications; and reporting disease or infection exposure. Upon reporting suspected elder or dependent adultabuse or domestic violence, we will promptly inform you or your personal representative unless we believe thenotification would place you at risk of harm or would require informing a personal representative we believe isresponsible for the abuse or harm.

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Abuse or NeglectWe may disclose your health informataon to appropriate authorities af we reasonably believe that you are apossible victim of abuse, neglect or domestic violence or the possible victim of other crimes. We may discloseyour health information to the extent necessary to avert a serious threat to y6ur health or safety or the healthor safety of others.

National SecurityWe may disclose to military authorities the health information of Armed Forces personnel under certaincircumstances. We may disclose to authorized federal officials heatth information required for laMulintelligence, counterintelligence and other national security activities. We may disclose to correctionalinstitutions or law enforcement omcials having lawful custody of protected health information of inmates orpatients under certain circumstances.

Appointment RemindersWe may contact you to provide you with appointment reminders via voicemail, postcards or letters. W'e mayalso leave a message wath the person answering the phone if you are not available.

Sign-ln Sheet and AnnouncementUpon arriving at our office, we may use and disclose medical information about you by asking that you sign anintake sheet at our front desk. we may also announce your name when we are ready to see you.

AccessYou have he right to look at or get mpies of your heatth information, with rimited exceptions. you may request thatwe provide copies in a format other than photocopies. we wi, use the format you requesl unrbss we cannotpracticably do so You must make a request in writing to obtain access to your health information. you may obtain aform to request access by contacting our offce. w" *[

"t rrg" y* a reasonable cost-based fee for expenscs suchas copies and staff time. you may arso request access by "e"noing

,s a rett"r- rf you request copies, there may be acharge for time spent lf you request an altemate format, we will c"harge a cosrbased fee for providing your healthinformatjon in that format- lf you prefer, we will prepare a srr."f o,- "n

urplanation of your health information fgr afee. contact us for a fufl expranation cf our fee structure. " vr i v^psr Euvr r ur vuur l rearur rllr(

Disc106ure AccountingYou have a right to receive a list of instances in which we discrosed your hearth information for purposes oiherthan treatment' payment, health care operations and certain other acrivities for the last six years. lf yourequest this accounting more than once in a 12-month period, we may charge you a reasonabre cost-basedfee for responding to these additional requests.

RestrictionYou have the right to request that we olace additional restrictionsinrormation. w" r," not,."qriod to asree to these aooitionar resirlJr#i[1;'J:TI1:";i:Hi:i]ti*agreement (except in emergency). ln the event you pay out-of-pocket and in full for servjces rendered, youmay request that we not share your health information with your health plan. we must agree to this request.Altemative CommunicationYou have the right to request thatwe communicate with you about your health information by alternativemeans or to arternative rocations you must make your request in writing. your request must specify thealternative means or location and piovide satisfactory explanation ot now payments will be handled unrler thealternatlve means or location you request.

Breach Notificationln the event your unsecured protected health information is breached, we will notify you as required by law. ln someslfuations, you may be notified by our business associates.

AmendmentYou have the right to request that we amend your health information. (your request must be in writing, and itmust exprain why the information shourd be amended). we may deny your request under certaincircumstances.

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lf you want more information about our privacy practices or have questions or concerns, please contact us at:

Email.

contad StAoeq L.Tetephone: La* t- 7)1-1301one Lalt t- 7)1- l5Ol rax: Wn i_ 7?'-l_e: la O

k'"n clr's €. pn r bzil , r,-ttAddress:

lf you are concerned that we may have violated your privacy rights, or you disagree with a decision we rnadeabout access to your health information or in response to a request you made to amend or restrict the use ordisclosure of your health information or to have us communicate with you by alternative means or atalternative locations, you may send a written complaint to our office or to the u.S. Department of Health andHuman services, office of civir Rights. we wifl not retariale against you for firing a compraint.

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