HIPAA

NOTICE OF PRIVACY PRACTICES (DENTAL)

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.

The Health Insurance Portability & Accountability Act of 1996 ("HIPAA") is a federal program that requires
that all medical records and other individually identifiable health information used or disclosed by us in any
form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the
patient, significant new rights to understand and control how your health information is used. "HIPAA"
provides penalties for covered entities that misuse personal health information.

As required by "HIPAA", we have prepared this explanation of how we are required to maintain the privacy
of your health information and how we may use and disclose your health information.

We may use and disclose your medical records only for each of the following purposes: treatment,
payment and health care operations.

• Treatment means providing, coordinating, or managing health care and related services by one or more
health care providers. An example of this would include teeth cleaning services.

• Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or
collection activities, and utilization review. An example of this would be sending a bill for your visit to your
insurance company for payment.

• Health care operations include the business aspects of running our practice, such as conducting quality
assessment and improvement activities, auditing functions, cost-management analysis, and customer
service. An example would be an internal quality assessment review.

We may also create and distribute de-identified health information by removing all references to
individually identifiable information.

We may contact you to provide appointment reminders or information about treatment alternatives or
other health-related benefits and services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such
authorization in writing and we are required to honor and abide by that written request, except to the
extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise
by presenting a written request to the Privacy Officer:

• The right to request restrictions on certain uses and disclosures of protected health information,
including those related to disclosures to family members, other relatives, close personal friends, or any
other person identified by you. We are, however, not required to agree to a requested restriction. If we
do agree to a restriction, we must abide by it unless you agree in writing to remove it.

• The right to reasonable requests to receive confidential communications of protected health
information from us by alternative means or at alternative locations.

• The right to inspect and copy your protected health information.

• The right to amend your protected health information.

• The right to receive an accounting of disclosures of protected health information.

• The right to obtain a paper copy of this notice from us upon request.

We are required by law to maintain the privacy of your protected health information and to provide you
with notice of our legal duties and privacy practices with respect to protected health information.

This notice is effective as of this day, this month and this year we are required to abide by the terms of
the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our
Notice of Privacy Practices and to make the new notice provisions effective for all protected health
information that we maintain. We will post and you may request a written copy of a revised Notice of
Privacy Practices from this office.

You have recourse if you feel that your privacy protections have been violated. You have the right to file
written complaint with our office, or with the Department of Health & Human Services, Office of Civil Rights,
about violations of the provisions of this notice or the policies and procedures of our office. We will not
retaliate against you for filing a complaint.

Please contact us for more information:

For more information about HIPAA or to file a complaint:

The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington D.C. 20201
(202) 619-0257
Toll Free: 1-877-696-6775