Notice
of Privacy
Practices

For certain purposes, we may disclose your health information without your authorization, including the following:

Treatment, Payment, and Health Care Operations:

The most common reason we use or disclose your health information is for treatment, payment, or health care operations.

Treatment: To treat you, we may use or disclose your information. Treatment may include, but is not limited to, developing a draft treatment plan or communicating with a dental laboratory regarding dental appliances being developed or modified for you, scheduling an appointment for you, conducting a dental exam, or perform diagnostic tests, prescribe medications, and fax or electronically submit for completion, refer you to another healthcare provider for additional or specialized services, or obtain copies of your medical information from another healthcare provider that you have seen before.

Payment: To obtain payment for the services we provide to you, we may use or disclose your information. Such instances include, but are not limited to, the use of your information to ask you or your insurance company about your dental insurance coverage or other sources of payment, to prepare and submit invoices or claims, or to collect unpaid amounts (either ourselves or through a contracted third party).

Healthcare Operations: For certain clerical and administrative activities that are necessary for us to run our business, we may use or disclose your information. Such instances include, but are not limited to, disclosing your information to train or evaluate our staff, conduct financial or billing audits for internal quality control, participate in managed care plans, advocate for legal matters, conduct business planning, or contract the storage of our records.

You Can Object to Disclosures: We We may disclose your health information to a friend, family member, or other person who is involved in your medical and dental care, except with your explicit instruction not to do so.

To remind you of scheduled appointments or the need for a routine appointment, including for dental monitoring, we may need to call, write, email or message you, that is, "get in touch." We may also contact you to notify you of other available treatments or services that may help you.

In addition, we may communicate to follow up, perform quality evaluations, request reviews, comments, satisfaction evaluations, complaints or similar activities.

We will not use your information for marketing purposes without your authorization. You understand that if we contact you to request a marketing authorization, and if you refuse to provide such consent, this will not affect your treatment and we will not repeatedly bother you about such authorization.

We may also use or disclose your information without your permission, in some limited situations and if certain conditions are met. These are some of the disclosures that may occur, but are not guaranteed to occur, and some disclosures will not be made by us, but under the jurisdiction of state or federal law:

• when a state or federal law mandates that certain health information be reported for a specific purpose;
• for public health purposes, such as communicable disease reporting, investigation or surveillance, and advisories to and from the Federal Food and Drug Administration regarding drugs or medical devices;
• to government authorities about victims of suspected abuse, neglect or domestic violence;
• for health oversight activities, such as for the licensing of dentists, for audits by Medicare or Medicaid, or for investigation of possible violations of health care laws;
• for judicial and administrative proceedings, such as in response to subpoenas or orders from courts or administrative agencies;
• for law enforcement purposes, such as providing information about someone who is or is suspected of being the victim of a crime, to report or provide information about a crime;
• to a coroner to identify a dead person or determine the cause of death, or to funeral directors to assist with burial, or to organizations that handle organ or tissue donations;
• for health-related research that has been approved by an Institutional Review Board or its equivalent;
• to prevent a serious threat to health or safety;
• for specialized government functions, such as the protection of the president or high-ranking government officials, for lawful national intelligence activities, for military purposes, or for the evaluation and health of foreign service members;
• disclosures of unidentified information;
• disclosures related to workers' compensation programs;
• disclosures of a "limited data set" for research, public health, or health care operations;
• incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
• disclosures to "business associates" who perform health care operations for us and who agree to comply with the privacy and security laws and regulations that apply to them.

Unless you sign a written "authorization form," we will not make any other use or disclosure of your information. Federal law determines the content of this "authorization form." We can start the authorization process if the use or disclosure is our idea, but you can start the process if it is your idea that we send your information to someone else.

In situations like the above, you will give us a properly completed authorization form or you can use one of ours.

You do not have to sign the authorization form if we start the process and ask you to sign it. If you choose not to sign the authorization, we cannot make the use or disclosure.

You can revoke the authorization form at any time unless we have already acted relying on it. Your withdrawal of authorization must be in writing and sent to the contact address named at the beginning of this Notice.

Before releasing any information related to mental health, substance abuse, HIV or AIDS treatment, we will request your authorization. We will also request your written authorization for most uses and disclosures of any psychotherapy note, your health information for marketing purposes, and for sale if your health information.

You many rights regarding your health information as governed by the law. To request any of the following, send a written request to the contact address named at the beginning of this Notice:

• Ask us to restrict our uses and disclosures for the purposes of treatment (except emergency treatment), payment, or health care operations. We are required by law to accept a request to restrict the release of your health information to a health plan if the disclosure is for payment, health care operations, and concerns a health care item or service for which you paid in full. out of your pocket. Except as described in the sentence above, we do not have to agree to your request, but if we do agree, we must comply with any restrictions you want.
• request that we communicate with you confidentially. For example, calling you at a special number at certain specific times, mailing health information to a different address, or sending you only a specific personal email address. We will accept these requests if they are reasonable and if you pay us any additional costs deemed appropriate by performing strenuous tasks.
• request to see or receive photocopies of your health information. Generally, with a limited exception, you will be able to review or have a copy of your health information within 30 days of submitting the request. You may be charged for such photocopies in advance. If we deny your request, we will send you a written explanation and instructions on how to obtain an impartial review of our denial if one is legally available. By law, we are allowed a 30-day extension from the time you submit the request to give you access or photocopies if we send you written notice of the extension. If your information is available electronically, we will send it to you electronically in a mutually agreed upon format, such as PDF. You can request that electronic health information we hold about you be sent to another person you specify. We will send the information electronically to you where you request it, as long as your instructions are clear and there is no deniable reason for not complying with this request. There is a possibility that you may have to pay the cost of producing an electronic copy of your health information.
• request that we amend your health information if you believe it is incorrect or incomplete. If we agree, we will amend the information within 60 days of your request. All persons we know received the incorrect or incomplete documentation, as well as other persons you specify, the updated documentation will be sent to them. If we do not agree, you can write a statement of your position and we will include it with your health information along with any rebuttal statement that we may write. Once your position statement and / or our rebuttal is included in your health information, we will send your health information to you whenever we make an acceptable disclosure. We may have a 30-day extension of time, as required by law, to consider an amendment request if we notify you in writing of the extension.
• ask to receive a list of the disclosures we have made of your health information in the last six years or less. The law dictates that the list cannot include: disclosures for the purposes of treatment, payment or health care operations (unless we made disclosures from an electronic health record), disclosures that were made with your authorization; incidental disclosures; disclosures required by law; and certain other limited disclosures. You are eligible for one such list per year at no charge, otherwise you will be responsible for prepayment for more frequent lists. Generally, your request will be answered within 60 days of receipt, but by law we are allowed a 30-day extension of time if we notify you of the extension in writing.
• request additional printed copies of this Notice of Privacy Practices.
• request to be notified, as required by law, if there is ever a data breach involving your health information.

We must abide by the terms of this Notice of Privacy Practices and we reserve the right to change this Notice at any time as required by law. If we change this Notice, the new privacy practices will apply to all health information that we maintain and to all information that we may generate in the future. If we change our Notice of Privacy Practices, it will be available and posted in our office and on our website.

You may file a complaint with us or with the US Department of Health and Human Services, Office for Civil Rights if you believe that we have not adequately respected the privacy of your health information and we will not retaliate against you if you file a complaint. If you wish to complain to us, please send a written complaint to the contact address or email shown at the beginning of this Notice. Or, if you prefer, you can discuss your complaint in person at the store or over the phone.

If you would like more information about our privacy practices, please call us, visit the contact address, or email us at the respective contact information listed at the beginning of this Notice.

This notice is effective May 1, 2019.