This Notice of Privacy Practices 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 to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. You may request a revised version by accessing our website, or calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment. 1. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION Your protected health information may be used and disclosed by your dentist, our office staff and others outside of our office who are involved in your care and treatment for the purpose of providing health care services to you. Following are examples of the types of uses and disclosures of your protected health information that your dentist’s office is permitted to make. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office. Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your dental care and any related services; such as a physician or other healthcare provider providing treatment to you, or to your family and friends you approve. Payment: Your protected health information will be used and disclosed, as needed, to obtain payment for services provided by us or by another provider. This may include certain activities that your health insurance plan may undertake before it approves or pays for the services we recommend for you. Health Care Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of our healthcare operations. These activities include, but are not limited to, quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certifications, licensing or credentialing activities. Required By Law: We may use or disclose your health information when we are required to do so by law or by national security activities. Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws. Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information. Treatment Photographs: We may utilize photographs taken during treatment, such as before and after photos, for promotional or educational materials. These materials might include printed or electronic publications, Web sites or other electronic communications. Your name and/or identity will not be revealed without your prior written authorization. Workers’ Compensation: We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legally-established programs. Others Involved in Your Health Care or Payment for your Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards or letters).   2. YOUR RIGHTS Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights. Access: You have the right to look at or review copies of your health information with limited exceptions. If you request copies, we will charge you $25.00 to locate your information, and postage if you want the copies mailed to you. Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and must explain why the information should be amended.) We may deny your request under certain circumstances.   3. COMPLAINTS If you want more information about our privacy practices or concerns, please contact us. You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a complaint. You may contact our Privacy Officer, Wendy at 713. 790.0288 for further information about the complaint process. This notice was published and becomes effective on January 1, 2011.

Welcome to our office! We are pleased to welcome you to our office and are happy you have chosen us for your periodontal consultation. It is our aim to meet all of your periodontal needs with the highest quality of care in the most welcoming and compassionate environment possible. During the initial visit, Dr. Brownfield will determine if a problem exists and will review the possible treatment options with you. We will work closely with your general dentist to keep him/her advised on your progress. To expedite your visit, please fill out all of the forms completely and bring them with you to your initial appointment. Cancellation Policy: If you find that you must change your appointment, we request the courtesy of 48 hours' notice so we can accommodate our other patients. Patients will be assessed a fee of $76 for a late cancellation of or no-show to periodontal maintenance appointments. This fee will be automatically billed to the patient's credit card on file if available, or will be due before that patient's next appointment can be scheduled. Financial Policy: We request full payment for the initial visit at the time of the appointment. Payment for dental/periodontal services is due at the time the services are provided, unless the patient has made prior arrangements with our office. For all procedures/surgeries, a non-refundable deposit of $500 will be collected at the time the appointment is scheduled. This deposit will be credited toward the cost of the dental/periodontal services rendered on the date of the appointment. Late cancellation of (within 5 working days) or no-show to procedures/surgeries will result in patient forfeiting the $500 deposit. For your convenience, we accept cash, and most major credit cards. For our patients with insurance, we make our treatment recommendations based on what we believe is the very best treatment, regardless of your specific insurance coverage. Insurance coverage is designed to cover minimal to standard care, and for that reason it is not uncommon for dental benefits to not cover all of our fees. It is our office policy to review all potential treatment costs and payment concerns with you in advance, in private, and to help you identify any available medical and/or dental insurance benefits. Our office will also gladly assist patients in preparing the forms or reports necessary for them to obtain their insurance benefits. However, our help in filling out a claim form DOES NOT GUARANTEE PAYMENT by the insurance company. The final determination of payment will be made by your insurance benefits provider at the time the claim is processed. Benefits payable are determined according to the insured's eligibility, the limitations and exclusions (including pre-existing limitations), and conditions of the plan. Even after receiving a pre-estimate, your benefits provider will not guarantee their information, so we regret that we cannot be responsible for any discrepancies in benefits represented. If you have any questions or need further information, don't hesitate to contact us at 713.790.0288.

YOUR SIGNATURE IS NECESSARY FOR US TO: PROCESS ALL INSURANCE CLAIMS; ENSURE PAYMENT FOR SERVICES PROVIDED; REALEASE MEDICAL INFOMARTION TO INSURANCE COMPANIES NEEDED FOR THE PROCESSING OF YOUR CLAIMS; RELEASE INFORMATION TO OTHER MEDICAL DENTAL PROVIDERS, INCLUDING LABORATORIES, WHEN NECESSARY, FOR YOUR TREATMENT.   I hereby authorize the release of all medical information necessary to process my claims and I authorize release of this same information, when necessary, to other providers rendering medical/dental care, as well as to labs that need my information to make a diagnosis or fabricate an appliance necessary for my treatment. I assign all medical and surgical benefits, including major medical benefits to which I am entitled, to Lauren A. Brownfield, DDS, MS, PA. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is considered to be as valid as the original.