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This Notice of Privacy Practices describes howe we, our Business Associates, and their subcontractors,
may use and disclose your protected health information (PHI) to carry out treatment, payment, or
health care operations (TPO), and for other purposes that are permitted or required by law. It also
describes your rights to access and control your protected health information. “Protected Health
Information” includes demographic information, that may identify you and relates to your past, present,
or future physical or mental health condition and related health care services including dental care.
This Notice takes effect on 1/1/2023. We reserve the right to make updates. Updated Notices will be
available in our office as well as on our website.
We are required by the Health Insurance Portability and Accountability Act of 1996 (“HIPPAA”) and
other applicable laws to maintain the privacy of your health information, to provide individuals with this
Notice of our legal duties and privacy practices with respect to such information, and to abide by the
terms of this Notice. To obtain a copy please contact the office or visit our website at
Your protected health information may be used and disclosed by our office and others outside of our
office that are involved in your care and treatment for the purpose of providing health care services to
you, to pay your health care bills, to support the operation of our practice, and any other use required
by law.
Treatment: We will use and disclose your protected health information to provide, coordinate, or
manage your care and any related services. This includes the coordination or management of your
health care with a third party. For example, your PHI ma be provided to another provider to whom you
have been referred so they have the necessary information to treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for your
services, such as filing for insurance benefits as applicable or resolving financial disputes.
Healthcare Operations: We may use or disclose your protected health information as needed, in order
to support the business activities of our practice. These activities include, but are not limited to, quality
assessment, employee review, training of interns, licensing, billing services, and other business activities.
We may also use a sign-in sheet, call you by name in the waiting room, send appointment reminders via
phone, email, or text, and inform you about treatment alternatives or other health-related benefits and
services that may be of interest to you. We may take intra oral and facial photos for treatment-related
purposes. If we use or disclose your PHI for fundraising activities, we will provide you the choice to opt
out. You may also choose to opt back in.
We may use or disclose your protected health information in the following situations without your
authorization. These situations include as required by law, public health issues as required by law,
communicable diseases, health oversight, abuse or neglect, food and drug administration requirements,
legal proceedings, law enforcement, coroners, funeral directors, organ donation research, criminal


activity, military activity and national security, workers’ compensation, inmates, and other required uses
and disclosures. We will make disclosures to you upon your request.
Under the law, we must also disclose your protected health information when required by the Secretary
of the Department of Health and Human Services to investigate or determine our compliance with the
requirements under Section 164.500.
Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization,
or opportunity to object, unless required by law. We may disclose your PHI to a personal
representative, such as a spouse, relative, or caretaker involved in your care related to their
involvement in your treatment or payment of services providing you identify these individual(s) and
authorize the release of information. If a young adult age of legal age requests that their information
not be released to a parent or guardian, we must comply with this request.
Without your authorization, we are expressly prohibited from using or disclosing your PHI for marketing,
fundraising, or research purposes. We may not sell your PHI without your authorization. You may
revoke these authorizations, at any time, in writing, except to the extent that we have already taken an
action based upon your prior authorization.
You have the right to inspect and copy your protected health information (fees may apply) –
Pursuant to your written request, you have the right to inspect or copy your PHI whether in paper or
electronic format. Under federal law, however, you may not inspect or copy the following records:
Psychotherapy notes, information complied in reasonable anticipation of, or used in, a civil, criminal, or
administrative action or proceeding. PHI restricted by law, information that is related to research in
which you have agreed to participate, information whose disclosure may result in harm or injury to you
or to another person, or information that was obtained under a promise of confidentiality.
Your have the right to request a restriction of your protected health information – This means you may
ask us not to use or disclose any part of your PHI for the purposes of treatment, payment, or healthcare
operations. You may also request that any part of your PHI not be disclosed to family members or
friends who may be involved in your care or for notification purposes as described in this Notice. Your
request must state the specific restriction requested and to whom you want the restriction to apply.
We are not required to agree to your requested restriction except if you request that we not disclose
PHI to your health plan with respect to healthcare for which you have paid in full out of pocket.

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