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Notice of Privacy Practice

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.

1. OUR PLEDGE REGARDING DENTAL INFORMATION

The privacy of your dental information is important to us.  We understand that your medical information is personal and we are committed to protecting it.  We create a record of the care and services you receive at our dental office.  We need this record to provide you with the quality care and to comply with certain legal requirements.  This notice will tell you about the ways we may use and share dental information with you.  We also describe your rights and certain duties we have regarding the use and disclosure of dental information.  Throughout this notice we refer to your medical information as dental information.

2. OUR LEGAL DUTY

Law Requires Us to:

1. Keep your dental information private
2. Give you this notice describing our legal duties, privacy practices, and your rights regarding you dental information.
3. Follow the terms of the current notice.

We Have the Right to:

1. Change our privacy practices and the terms of this notice at any time, provided that law permits the changes.
2. Make the changes in our privacy practices and the new terms of our notice effective for all dental information that we keep, including information previously created or received before the changes.

Notice of Change to Privacy Practices:

1. Before we make an important change in our privacy practices, we will change this notice and make the new notice available upon request.

3. USE AND DISCLOSURE OF YOUR DENTAL INFORMATION

The following section describes different ways that we use and disclose dental information.  For each kind of use or disclosure, we will explain what we mean and give an example.  Not every use or disclosure will be listed.  However, we have listed all the different ways we are permitted to use and disclose dental information.  We will not use or disclose your dental information for any purpose not listed below, without specific written authorization.  Any specific written authorization you provide may be revoked at any time by writing us at the address provided at the end of this notice.

FOR TREATMENT:  We may use dental information about you to provide you with dental treatment or services.  We may disclose dental information about you to doctors, nurses, technicians, or other people who are taking care of you.  We may also share dental information about you to your other health care providers to assist them in treating you.

FOR PAYMENT:  We may use and disclose your dental information for payment purposes.  A bill may be sent to you or a third-party payer.  The information on or accompanying the bill may include your dental information.

FOR HEALTH CARE OPERATIONS:  We may use and disclose your dental information for our health care operations.  This might include measuring and improving quality, evaluating the performance of employees, conducting training programs, and getting the accreditation, certificates, licenses and credentials we need to serve you.

ADDITIONAL USES AND DISCLOSURES:  In addition to using and disclosing your dental information for treatment, payment, and health care operations, we may use and disclose dental information for the following purposes.

Notification:  We may use and disclose dental information to notify or help notify: a family member, your personal representative or another person responsible for your care.  If you are present, we will get your permission if possible before we share, or give you the opportunity to refuse permission.  In case of emergency, and if you are not able to give or refuse permission, we will share only the health information that is directly necessary for your health care, according to our professional judgment.  We will also use our professional judgment to make decisions in your best interest about allowing someone to pick up medicine, dental supplies, x-ray or other dental information for you.

Research In Limited Circumstances:  We may use medical information for research purposes in limited circumstances where the research has been approved by a review board that has reviewed the research proposal and established protocols to ensure the privacy of dental information.

Funeral Director, Coroner, and Medical Examiner:  To help them carry out their duties, we may share the dental information of a person who has died with a coroner, medical examiner, funeral director, or an organ procurement organization.

Specialized Government Functions:  Subject to certain requirements, we may disclose or use dental information for military personnel and veterans, for national security and intelligence activities, for protective services, for the President and others, for medical suitability determinations for the Department of State, for correctional institutions and other law enforcement custodial situations, and for government programs providing public benefits.

Court Orders and Judicial and Administrative Proceedings:  We may disclose dental information in response to a court or administrative order, subpoena, discovery request, or other lawful process, under certain circumstances.  Under limited circumstances, such as a court order, warrant, a grand jury subpoena, we may share your dental information with law enforcement officials.  We may share limited information with a law enforcement official concerning the dental information of a suspect, fugitive, material witness, crime victim or missing person.  We may share the dental information of an inmate or other person in lawful custody with a law enforcement official or correctional institution under certain circumstances.

Public Health Activities:  As required by law, we may disclose your dental information to public health or legal authorities charged with preventing or controlling disease, injury or disability, including child abuse or neglect.  We may also disclose your dental information to persons subject to jurisdiction of the Food and Drugs Administration for purposes of reporting adverse events associated with product defects or problems, to enable product recalls, repairs or replacements, to track products, or to conduct activities required by the Food and Drug Administration.  We may also, when we are authorized by law to do so, notify a person who may have been exposed to a communicable disease or otherwise be at risk of contracting or spreading a disease or condition.

Victims of Abuse, Neglect, or Domestic Violence:  We may use and disclose dental 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 share your dental information if it is necessary to prevent a serious threat to your health or safety or the health or safety of others.  We may share dental information when necessary to help law enforcement officials capture a person who has admitted to being part of a crime or has escaped from legal custody.

Workers Compensation:  We may disclose dental information when authorized or necessary to comply with laws relating to workers compensation or other similar programs.

Health Oversight Activities:  We may disclose dental information to an agency providing health oversight for oversight activities authorized by law, including audits, civil, administrative, or criminal investigations or proceedings, inspections, licensure or disciplinary actions, or other authorized activities.

Law Enforcement:  Under certain circumstances, we may disclose dental information to law enforcement officials.  These circumstances include reporting required by certain laws (such as reporting of certain types of wounds), pursuant to certain subpoenas or court orders, reporting limited information concerning identification and location at the request of a law enforcement official, reports regarding suspected victims or crimes at the request of a law enforcement official, reporting death, crimes on our premises, and crimes in emergencies.

Appointment Reminders:  We may use and disclose dental information for purposes of sending you appointment postcards or otherwise reminding you of your appointments.

Alternative and Additional Dental Services:  We may use and disclose dental information to furnish you with information about health-related benefits and services that may be of interest to you, and to describe or recommend treatment alternatives.

4. YOUR INDIVIDUAL RIGHTS

You Have the Right to:

1. 1. Look at or get copies of certain parts of your dental information.  You may request that we provide copies in a format other than photocopies.  We will use the format you request unless it is not practical for us to do so.  You may make your request in writing.  You may get the form to request access by using the contact information listed at the end of this notice.  If you request copies, we will charge you $____________ for each page, and postage of you want the copies mailed to you.  Contact us using the information listed at the end of this notice for a full explanation of our fee structure.
   2. Receive a list of all the times our business associates or we shared your dental information for purposes other than treatment, payment, and health care operations and other specified exceptions.
   3. Request that we place additional restrictions on our use or disclosure of your dental information.  We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in the case of emergency).
   4. Request that we communicate with you about your dental information by different means or at different locations must be made in writing to the contact person listed at the end of this notice.
   5. Request that we change certain parts of your dental information.  We may deny your request if we did not create the information you want changed or for certain other reasons.  If we deny your request, we will provide you a written explanation.  You may respond with a statement of disagreement that will be added to the information you want changed.  If we accept your request to change the information, we will make reasonable efforts to tell others, including people you name, of the change and to include the changes in any future sharing of that information.
   6. If you have received this notice electronically, and wish to receive a paper copy, you have the right to obtain a paper copy by making a request in writing to the contact person listed at the end of this notice.