I. Dental Practice Covered by this Notice

This Notice describes the privacy practices of Wisdom Partner DDS PLLC (“Dental Practice” “We” and “our” means the Dental Practice. “You” and “your” means our patient.

II. How to Contact Us/Our Privacy Official

If you have any questions or would like further information about this Notice, you can contact Dr. Foust. 21715 Kingsland Blvd., #105 Katy, TX 77450-2544 E-mail: DrFoust@wisdompartnerDDS.com Voice Mail: (832) 600-6878 Fax: (888) 565-5188

III. Our Promise to You and Our Legal Obligations

• The privacy of your health information is important to us. We understand that your health information is personal and we are committed to protecting it. This Notice describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations 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 is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. We are required by law to:
• Give you this Notice of our legal duties and privacy practices with respect to that information; and • Abide by the terms of our Notice that is currently in effect.

This Notice was last revised on 3/1/17

V. How We May Use or Disclose Your Health Information

The following examples describe different ways we may use or disclose your health information. These examples are not meant to be exhaustive. We are permitted by law to use and disclose your health information for the following purposes: A. Common Uses and Disclosures 1. Treatment. We may use your health information to provide you with dental treatment or services, such as cleaning or examining your teeth or performing dental procedures. We may disclose health information about you to dental specialists, physicians, or other health care professionals involved in your care. 2. Payment. We may use and disclose your health information to obtain payment from health plans and insurers for the care that we provide to you. 3. Health Care Operations. We may use and disclose health information about you in connection with health care operations necessary to run our practice, including review of our treatment and services, training, evaluating the performance of our staff and health care professionals, quality assurance, financial or billing audits, legal matters, and business planning and development. 4. Appointment Reminders. We may use or disclose your health information when contacting you to remind you of a dental appointment. We may contact you by using a postcard, letter, phone call, voice message, text or email. 5. Treatment Alternatives and Health-Related Benefits and Services. We may use and disclose your health information to tell you about treatment options or alternatives or health-related benefits and services that may be of interest to you. 6. Disclosure to Family Members and Friends. We may disclose your health information to a family member or friend who is involved with your care or payment for your care if you do not object or, if you are not present, we believe it is in your best interest to do so. 7. Disclosure to Business Associates. We may disclose your protected health information to our third-party service providers (called, “business associates”) that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use a business associate to assist us in maintaining our practice management software. All of our business associates are obligated, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract. B. Less Common Uses and Disclosures 1. Disclosures Required by Law. We may use or disclose patient health information to the extent we are required by law to do so. For example, we are required to disclose patient health information to the U.S. Department of Health and Human Services so that it can investigate complaints or determine our compliance with HIPAA. 2. Public Health Activities. We may disclose patient health information for public health activities and purposes, which include: preventing or controlling disease, injury or disability; reporting births or deaths; reporting child abuse or neglect; reporting adverse reactions to medications or foods; reporting product defects; enabling product recalls; and notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. 3. Victims of Abuse, Neglect or Domestic Violence. We may disclose health information to the appropriate government authority about a patient whom we believe is a victim of abuse, neglect or domestic violence. 4. Health Oversight Activities. We may disclose patient health information to a health oversight agency for activities necessary for the government to provide appropriate oversight of the health care system, certain government benefit programs, and compliance with certain civil rights laws. 5. Lawsuits and Legal Actions. We may disclose patient health information in response to (i) a court or administrative order or (ii) a subpoena, discovery request, or other lawful process that is not ordered by a court if efforts have been made to notify the patient or to obtain an order protecting the information requested. 6. Law Enforcement Purposes. We may disclose your health information to a law enforcement official for a law enforcement purposes, such as to identify or locate a suspect, material witness or missing person or to alert law enforcement of a crime. 7. Coroners, Medical Examiners and Funeral Directors. We may disclose your health information to a coroner, medical examiner or funeral director to allow them to carry out their duties. 8. Organ, Eye and Tissue Donation. We may use or disclose your health information to organ procurement organizations or others that obtain, bank or transplant cadaveric organs, eyes or tissue for donation and transplant. 9. Research Purposes. We may use or disclose your information for research purposes pursuant to patient authorization waiver approval by an Institutional Review Board or Privacy Board. 10. Serious Threat to Health or Safety. We may use or disclose your health information if we believe it is necessary to do so to prevent or lessen a serious threat to anyone’s health or safety. 11. Specialized Government Functions. We may disclose your health information to the military (domestic or foreign) about its members or veterans, for national security and protective services for the President or other heads of state, to the government for security clearance reviews, and to a jail or prison about its inmates. 12. Workers' Compensation. We may disclose your health information to comply with workers' compensation laws or similar programs that provide benefits for work-related injuries or illness.

VI. Your Written Authorization for Any Other Use or Disclosure of Your Health Information

Uses and disclosures of your protected health information that involve the release of psychotherapy notes (if any), marketing, sale of your protected health information, or other uses or disclosures not described in this notice will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke this authorization at any time, in writing, except to the extent that this office has taken an action in reliance on the use of disclosure indicated in the authorization. If a use or disclosure of protected health information described above in this notice is prohibited or materially limited by other laws that apply to use, we intend to meet the requirements of the more stringent law.

VII. Your Rights with Respect to Your Health Information

You have the following rights with respect to certain health information that we have about you (information in a Designated Record Set as defined by HIPAA To exercise any of these rights, you must submit a written request to our Privacy Official listed on the first page of this Notice. A. Right to Access and Review You may request to access and review a copy of your health information. We may deny your request under certain circumstances. You will receive written notice of a denial and can appeal it. We will provide a copy of your health information in a format you request if it is readily producible. If not readily producible, we will provide it in a hard copy format or other format that is mutually agreeable. If your health information is included in an Electronic Health Record, you have the right to obtain a copy of it in an electronic format and to direct us to send it to the person or entity you designate in an electronic format. We may charge a reasonable fee to cover our cost to provide you with copies of your health information. B. Right to Amend If you believe that your health information is incorrect or incomplete, you may request that we amend it. We may deny your request under certain circumstances. You will receive written notice of a denial and can file a statement of disagreement that will be included with your health information that you believe is incorrect or incomplete. C. Right to Restrict Use and Disclosure You may request that we restrict uses of your health information to carry out treatment, payment, or health care operations or to your family member or friend involved in your care or the payment for your care. We may not (and are not required to) agree to your requested restrictions, with one exception: If you pay out of your pocket in full for a service you receive from us and you request that we not submit the claim for this service to your health insurer or health plan for reimbursement, we must honor that request. D. Right to Confidential Communications, Alternative Means and Locations You may request to receive communications of health information by alternative means or at an alternative location. We will accommodate a request if it is reasonable and you indicate that communication by regular means could endanger you. When you submit a written request to the Privacy Official listed on the first page of this Notice, you need to provide an alternative method of contact or alternative address and indicate how payment for services will be handled. E. Right to an Accounting of Disclosures You have a right to receive an accounting of disclosures of your health information for the six (6) years prior to the date that the accounting is requested except for disclosures to carry out treatment, payment, health care operations (and certain other exceptions as provided by HIPAA The first accounting we provide in any 12-month period will be without charge to you. We may charge a reasonable fee to cover the cost for each subsequent request for an accounting within the same 12-month period. We will notify you in advance of this fee and you may choose to modify or withdraw your request at that time. F. Right to a Paper Copy of this Notice You have the right to a paper copy of this Notice. You may ask us to give you a paper copy of the Notice at any time (even if you have agreed to receive the Notice electronically To obtain a paper copy, ask the Privacy Official. G. Right to Receive Notification of a Security Breach We are required by law to notify you if the privacy or security of your health information has been breached. The notification will occur by first class mail within sixty (60) days of the event. A breach occurs when there has been an unauthorized use or disclosure under HIPAA that compromises the privacy or security of your health information. The breach notification will contain the following information: (1) a brief description of what happened, including the date of the breach and the date of the discovery of the breach; (2) the steps you should take to protect yourself from potential harm resulting from the breach; and (3) a brief description of what we are doing to investigate the breach, mitigate losses, and to protect against further breaches.

VIII. Special Protections for HIV, Alcohol and Substance Abuse, Mental Health and Genetic Information

Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including HIV-related information, alcohol and substance abuse information, mental health information, and genetic information. For example, a health plan is not permitted to use or disclose genetic information for underwriting purposes. Some parts of this HIPAA Notice of Privacy Practices may not apply to these types of information. If your treatment nvolves this information, you may contact our office for more information about these protections.

IX. Our Right to Change Our Privacy Practices and This Notice

We reserve the right to change the terms of this Notice at any time. Any change will apply to the health information we have about you or create or receive in the future. We will promptly revise the Notice when there is a material change to the uses or disclosures, individual’s rights, our legal duties, or other privacy practices discussed in this Notice. We will post the revised Notice on our website (if applicable) and in our office and will provide a copy of it to you on request. The effective date of this Notice is 3/1/17.

X. How to Make Privacy Complaints

If you have any complaints about your privacy rights or how your health information has been used or disclosed, you may file a complaint with us by contacting our Privacy Official listed on the first page of this Notice. You may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you in any way if you choose to file a complaint.

I have received a copy of Wisdom Partner DDS, PLLC’s Notice of Privacy Practices effective 3/1/17.

By signing below I acknowledge my active commitment to keep my appointment to help make sure that all patients are getting the care they need. I agree to arrive at least 15 minutes early. 

You have the right, as a patient, to be informed about your condition and about the recommended surgical, medical, or diagnostic procedures to be used so that you may make the decision whether or not to undergo the procedure after knowing the risks and hazards involved. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so you can give or withhold your consent to the procedure.

I voluntarily request R.T. Foust IV, DDS and such associates, technical assistants, and other health care providers as they may deem necessary, to treat my condition which has been explained to me as:

I understand that surgical, medical, and/or diagnostic procedures are planned for as outlined in my treatment plan, and I voluntarily consent and authorize these procedures under local anesthesia supplemental by IV Sedation including the use of platelet rich fibrin (PRF), bone grafting, the use of membranes or socket preservation.

I understand that my doctor may discover other or different conditions which require additional or different procedures than those planned. I authorize my doctor and such associates, technical assistants, and other health care providers to perform such other procedures which are advisable in their professional judgment.

I understand that no warranty or guarantee has been made to me as to result or cure. I have been given both oral and written post-operative instructions, and I agree to personally contact Dr. Foust in the event I have a problem. I will follow his instructions until that problem has been satisfactorily resolved. I realize that in the event I develop certain complications, I may miss school or work schedules or I may incur additional, unexpected expenses, including, but not limited to, expenses for other dentists, doctors, or medical facilities.

I understand Dr. Foust is not employed by my dentist but is an independent contractor and will receive a portion of the fee paid to my dentist for these services. I have chosen Dr. Foust from the alternatives I have been offered to perform my dental surgery. I understand that Dr. R.T. Foust and his colleagues are certified general dentists licensed to perform oral surgery and third molar (wisdom teeth) removal that they are not oral and maxillofacial surgeons. I choose not to be referred to an oral and maxillofacial surgeon for this procedure.

Just as there may be risks and hazards in continuing my present condition without treatment, there are also risks and hazards related to the performance of the surgical, medical, and/or diagnostic procedures planned for me. I realize that common to surgical, medical, and/or diagnostic procedures is the potential for infection, pain, swelling, bleeding, bruising, allergic reactions, cardiac arrest, brain injury, and even death. I also realize that the following risks and hazards may occur in connection with this particular procedure:

TO THE PATIENT: You have the right as a patient, to be informed about 1) the recommended anesthesia/analgesia to be used and 2) the risks related to anesthesia/analgesia. This disclosure is designed to provide this information so you can decide whether to consent to receive anesthesia in the perioperative period (meaning shortly before, during and shortly after a procedure). Please ask your healthcare provider any remaining questions you might have before signing this form.

The following is provided to inform our patients of the choices and risks involved with having treatment under anesthesia. This information is not presented to make patients more apprehensive but to enable them to be better informed concerning their treatment. The choices for pain and anxiety management are basically three: local anesthesia along, conscious sedation, or general anesthesia. These can be administered, depending upon each individual patient's medical requirements, either in an office or in a hospital setting.

I understand that IV conscious sedation and other forms of supplemental sedation involve additional risks and hazards, but I request the use of IV conscious sedation and/or other forms of supplemental anesthesia to assist in the relief and protection from pain during the planned and additional procedures. I realize that IV conscious sedation and/or other forms of supplemental anesthesia may have to be changed possibly without explanation to me. I understand this is not general anesthesia and that though it is unlikely, I may have unpleasant memories of the procedure.

I have been informed and understand that occasionally there are complications of the drugs and anesthesia, including but not limited to: pain, hematoma, numbness, intra-arterial injection, infection, swelling, bleeding, discoloration, nausea, vomiting, allergic reaction, and fluctuations in breathing pattern, heart rhythm, and/or blood pressure, drug reaction, awareness during the procedure, memory dysfunction/memory loss, permanent organ damage, brain damage, cardiac arrest, heart attack, coma, or death.  Some may be related to local anesthetic administration or intravenous/ intramuscular administration of agents.

Local anesthesia may be utilized with the procedure.  Complications (although rare) which can occur are pain, hematoma, numbness, intra-arterial injection, nerve damage, infection, swelling, bleeding, discoloration, persistent pain, and chronic pain.

I further understand and accept the risk that complications may require hospitalization. I have been made aware that the risks associated with anesthesia, conscious sedation, and general anesthesia vary. Of the three, local anesthesia is usually considered to have the least risk and general anesthesia the greatest risk. However, it must be noted that local anesthesia sometimes is not appropriate for every patient and every procedure.

I understand that anesthetics, medications, and drugs may be harmful to the unborn child and may cause birth defects or spontaneous abortion. Recognizing the risks, I accept full responsibility for informing the anesthesiologist of a suspected or confirmed pregnancy with the understanding that this will necessitate the postponement of the anesthesia. For the same reasons I understand that I must inform the anesthesiologist if I am a nursing mother.

Since administered medications may interact with current medications, (prescribed, over-the-counter, or non-prescribed, and others) it is important that the anesthesia provider be aware of all medications and drugs being taken as well as have a current medical history. Because medications, drugs, anesthetics, and prescriptions may cause drowsiness and incoordination which can be increased by the use of alcohol or other drugs, l have been advised not to operate any vehicle or hazardous device for at least 24 hours or longer until recovered from the effects of the anesthetic, medications, and drugs that may have been given to me for my care. I have been advised not to make any major decisions until after recovery from anesthesia.

I have been fully advised of and completely understand the alternatives to IV conscious sedation and accept the possible risks and dangers. I acknowledge the receipt of and understand both pre-operative and post-operative anesthesia instructions. This form has been fully explained to me, I have read it or it has been read to me. It has been explained to me and I understand there is no warranty or guarantee as to any result and/or cure. I have had the opportunity to ask questions about my anesthesia and am satisfied with the information provided to me.

I have been given an opportunity to ask questions about my condition, alternative forms of anesthesia and treatment, risks of non-treatment, the procedures to be used, and the risks and hazards involved, and I believe that I have sufficient information to give this consent.

I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any errors or omissions that I may have made in the completion of this form.

I, hereby authorize and request Dr. Foust to perform the anesthesia as previously explained to me and any other procedure deemed necessary or advisable as a corollary to the planned anesthesia. I consent, authorize, and request the administration of such anesthesia or anesthetics (from local to general) by any route that is deemed suitable to the administrator.

I consent to photographs of my oral and facial structures and of my patient documents regarding this procedure (confidential and for Dr. Foust’s records)

Patient's Ride may sign as a witness below

INFORMATION FOR PATIENTS REGARDING POSSIBLE CHANGES IN SENSATIONS OF THE LIP, CHIN, OR TONGUE FOLLOWING DENTAL SURGERY.

Dental surgery, like any other surgery, has certain inherent risks and limitations that may occur despite the experience and skill of the doctor. Following your surgery, it is possible that you may experience either temporary or permanent changes in the sensation or feelings of your lip, chin, or tongue. Permanent changes in sensation of the affected areas are extremely rare.

Because the nerves that supply these regions are close to the area where the surgery is performed, the nerves may not function normally for a while afterwards. These nerves affect sensation only and not movement. The most common cause of this type of injury is from the pressure that can occur during the removal of a tooth root in the lower jaw. Occasionally, hooks or curves on the root may tear some of the nerve fibers. Another possible cause of injury is during the administration of the local anesthesia (numbing medicine X-rays are helpful but cannot tell us the exact location of the important structures. When the nerve is especially close to the site of the surgery, it could be nicked or cut. Additionally, the incidence and severity of nerve injuries increases with age. This is particularly true for lower wisdom teeth. Further, sometimes sensation is affected without knowing exactly what caused it.

The likelihood that a change in sensation will occur and how long it will last can depend on many factors, including position of the tooth, the nerve, or the difficulty of the procedure. The duration of the condition is unpredictable and different in each case. It may last a few days, weeks, or months, and in very rare instances, may be permanent. In the majority of cases, the sensory loss gradually returns to normal although you may not be aware of any immediate improvement. Nerve tissue is the slowest tissue in the body to heal, and it can be weeks or months before you notice significant improvements. Nonetheless, it is important for you to stay in touch with us, so we may advise you of your specific circumstances.

During nerve recovery, you may notice changes such as tingling, as if a local anesthetic is wearing off. Other sensations may also be present. Do not be alarmed; this is often a positive sign. It is important for you to help us in recording any changes in your symptoms so that we may better answer your questions and advise you as to your prognosis.

If there has been absolutely no improvement in six weeks, then depending on your case, microsurgical repair could be considered. We can further council you on this possibility, and you will be referred to a specialist who is experienced and knowledgeable in this area.

Remember, in the overwhelming number of instances of altered sensation, all or most of the normal sensation will return. If residual symptoms do remain, the risks involved with surgical repair may not be warranted, in that spontaneous, post- operative recovery may take up to two years to occur. By keeping in close contact with us, we are better able to advise you throughout your recovery process to insure optimum results.

Patient's Ride may sign as a witness below