NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOUR MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are
also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your
health information. We must follow the privacy practices that are described in this Notice while it is in effect. This
Notice takes effect 4/14/2003, and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such
changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and
the new terms of our Notice effective for all health information that we maintain, including health information we
created or received before we made the changes. Before we make a significant change in our privacy practices,
we will change this Notice and make the new Notice available upon request.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for
additional copies of this Notice, please contact us using the information listed at the end of this Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For
example:
Treatment: We may use or disclose your health information to a physician or other healthcare provider providing
treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare
operations. Healthcare operations include quality assessment and improvement activities, reviewing the
competence or qualifications of healthcare professionals, evaluating practitioner and provider performance,
conducting training programs, accreditation, certification, licensing or credentialing activities.
Your Authorization: In addition to our use of your health information for treatment, payment or healthcare
operations, you may give us written authorization to use your health information to disclose it to anyone for any
purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect
any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written
authorization, we cannot use or disclose your health information for any reason except those describe in this
Notice.
To Your Family and Friends: We must disclose your health information to you, as described in the Patient
Rights section of this Notice. We may disclose your health information to a family member, friend or other person
to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that
we may do so.
Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of
(including identifying or locating) a family member, your personal representative or another person responsible for
your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of
your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event
of your incapacity or emergency circumstances, we will disclose health information based on determination using
our professional judgment disclosing only health information that is directly relevant to the person’s involvement in
your healthcare. We will also use of professional judgment and our experience with common practice to make

reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-
rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications
without your written authorization.
Required by Law: We may use or disclose your health information when we are required to do so by law.
Abuse or Neglect: We may use or disclose your health information to appropriate authorities if we reasonably
believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other
crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health
or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel
under certain circumstances. We may disclose to authorized federal officials health information required for lawful
intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution
or law enforcement official having lawful custody of protected health information of inmate or patient under certain
circumstances.
Appointment Reminders: We may use or disclose your health information to provide you with appointment
reminders (such as voicemail messages, postcards, letters, or emails).
PATIENT RIGHTS
Access: You have the right to look at or get copies of your health information, with limited exceptions. You may
request that we provide copies in a format other than photocopies. We will use the format you request unless we
cannot practicably do so. (You must make a request in writing to obtain access to your health information. You
may obtain a form to request access by using the contact information listed at the end of this Notice. We will
charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request
access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you
$5-$20/x-ray or photo. $0.00 per hour for staff time to locate and copy your health information, and postage if you
want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing
your health information in that format. If you prefer, we will prepare a summary or an explanation of your health
information for a fee. Contact us using he information listed at the end of the Notice for a full explanation of our
fee structure.)
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates
disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain
other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once
in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional
request.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your
health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our
agreement (except in an emergency).
Alternative Communication: You have the right to request that we communicate with you about your health
information by alternative means or to alternative locations. (You must make your request in writing.) Your
request must specify the alternative means or location, and provide satisfactory explanation how payments will be
handled under the alternative means or location you request.
Amendment: 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.
Electronic Notice: If you receive this Notice on our Website or by electronic mail (e-mail), you are entitled to
receive this Notice in written form.
QUESTIONS AND COMPLAINTS
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 right, 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 alternative means or at alternative locations,
you may complain to us using the contact information listed at the end of the Notice. You also may submit a
written complaint with the U.S. Department of Health and Human Services. We will provide you with the address
to file your complaint with 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.
© 2002 American Dental Association
All Rights Reserved

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES ***You may refuse to sign this Acknowledgement*** *
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES ***You may refuse to sign this Acknowledgement***
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