This notice describes how medical information about you may be used and

disclosed and how you can get access to this information.

PLEASE READ CAREFULLY

In our office, we keep your health information secure and confidential. The law requires us to maintain your privacy, to give you notice, and to follow the terms of this notice.

The law permits us to use or disclose your health information to those involved in your treatment. For example, we may show your file to a specialist doctor who may be involved in your care.

We may use or disclose your health information for payment of your services. For example, we may send a report of your progress to your insurance company.

We may use or disclose your health information for your normal healthcare operations. For example, one of our staff will enter your information into our computer system.

We may share medical information with our business associates, such as a billing service. We have a written contract with each business associate that requires them to protect your privacy.

We may use your information to contact you. For example, we may send newsletters, postcards, e-mails, text messages, or other information. We may also call and remind you about your appointments or leave this information on your answering machine or with the person who answers the phone.

In an emergency, we may disclose your health information to a family member or another person responsible for your care.

We may release your health information when required by law.

If this practice is sold, your information will become the property of the new owner.

Except as described above, this practice will not use or disclose your health information without prior written authorization.

You may request in writing that we not use or disclose your health information as described above.

You have the right to transfer copies of your health information to another practice. However, we do need you to fill out an “Authorization for the Release of Dental Records” form. A reasonable fee for the copies will be applied.

You have the right to see and receive a copy of your health information, with a few exceptions. A written request will be required.

You have the right to request an amendment or change to your health information. We will not remove nor alter earlier documents. A written request will be required.

You have the right to receive a copy of this notice.

If we change any of the details of this notice, we will notify you of the changes in writing.

You may file a complaint with:

The Department of Health and Human Services

200 Independence Avenue S.W., Room 509F

Washington, DC 20201