The following questions are for females only:

I affirm that the information given today is correct to the best of my knowledge. I understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical information.

I hereby authorize the release of any information pertaining to my child's medical treatment necessary to process insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.

OUR LEGAL DUTY

Federal and state law requires us to maintain the privacy of your health information. That law also requires us to give you this notice about our privacy practices, our legal duties, and your right concerning your health information. We must follow the privacy practices we describe in this notice while it is in effect. This notice takes effect October 19, 2016, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this notice at any time, provided such applicable law permits the changes. We reserve the right to make the changes in our privacy practices and the new terms of our notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant
change in our privacy practices, we will change the notice and make the new notice available upon request.

You may request a copy of our notice at any time. For more information about our privacy practices, or additional copies of this notice please contact us using the information listed at the end of this notice.

USES AND DISCLSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and health care operations. For example:

Treatment: We may use your health information for treatment or disclose it to a dentist, physician or other health care provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you. We may use and disclose your health information to another health care provider or entity that is subject to the Federal Privacy Rules for its payment activities.

Health Care Operations: We may use and disclose your health information for our health care operations. Health care operations include quality performance, conducting training programs, accreditation certificate, licensing or credentialing activities. We ay disclose your health information to another health care provider or organization that is subject to the feral privacy rules.

On Your Authorization: You may give us written authorization to use your health information to disclose it to anyone for any purpose. If you give us authorization, you may revoke it in writing at any time. Your revocation will not affect any uses or disclosures permitted by your authorization while it was in effect. Unless you give us written authorization, we cannot use or disclose health information for
any reason except those described in this notice.

To Your Family and Friends: We may disclose your health information to a family member, friend or other person to the extent necessary to help with your health care payment for your health care. Before we disclose your health information to those people, we will provide you with an opportunity to object to our use to disclosure. If you are not present, or in the event of your incapacity or an emergency, we will disclose your medical information based on our professional judgement of whether the disclosure would be in your best interest. We may use our professional judgement and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays or other similar forms of health information. We may use or disclose information about you to notify a person involved in your care, or your location and general condition.

Appointment Reminders: We may use or disclose your health information or provide you with appointment reminders such as voice mails messages, postcards, or letters.

Disaster Relief: We may use or disclose your health information to a public or private entity authorized by law or by its charter to assist in disaster relief efforts.

Public Benefit: We may use or disclose your medical information as authorized by law for following purposes deemed to be in the public interest or benefit.

*as required by law;

*for public health activities including disease and vital statistic reporting, child abuse reporting, FDA oversight, and to employers regarding work-related illness or injury;

*to report adult abuse, neglect, or domestic violence;

*to health oversight agencies;

*in response to court and administrative orders and other lawful processes;

*to law enforcement officials and pursuant to subpoenas and other lawful processes concerning crime victims, suspicious death, crimes on our premises, reporting crimes in emergencies, and for purpose of identifying or locating a suspect or other person;

*to coroner, medical examiners, and funeral directors;

*to an organ procurement organization;

*to avert a serious threat to health and safety;

*in connection with certain research activities;

To the military and to federal officials for lawful intelligence, counterintelligence, and national security activities;

*to correctional institutions regarding inmates; and

*as authorized by state worker's compensation laws.

PATIENT RIGHTS

Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practically do so. You must make a request in writing to obtain access to your health information. You may request access by sending us a letter to the address at the end of this notice. If you request copies we will charge you a reasonable cost-based fee that may include labor, copying costs and postage. If you request an alternate format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we may, but are not required to, prepare a summary of explanation of your health information for a fee. Contact us using the information listed at the end of this notice for more information about fees.

Disclosure Accounting: You have a right to receive a list of instances in which we or our business associates disclosed your health information over the last 6 years (but not before April 1, 2003). That list will not include disclosures for treatment, payment, health care operations, as authorized by you, and for certain other activities. If you request this accounting more than once in a 12 month period, we
may charge you a reasonable, cost-based fee for responding to these additional requests. Contact us using the information listed at the end of this notice for more information about fees.

Restriction: You have the right to request that we place additional restrictions on our use of disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our arrangement (except in an emergency). Any agreement to make a request for additional restrictions must be in writing signed by a person authorized to make such an agreement on our behalf. Your request is not binding unless our agreement is in writing.

Alternative Communications: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. You must make your request in writing. You must specify in your request the alternative means or location, and provide satisfactory explanation how you will handle payment under the alternative means or location request.

Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why we should amend the information. We may deny your request under certain circumstances.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us using the information listed at the end of this notice.

If you believe that:

*we may have violated your privacy rights,

*we made a decision about access to your health information incorrectly,

*our response to a request you made to amend or restrict the use of disclosure of your health information was incorrect, or

*we should communicate with you by alternative means or alternative locations,
You may contact us using the information below. You also may submit a written complaint to the U.S. Departments of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Frederick S. Fritz, DDS, LLC
15200 Shady Grove Road
Suite 201
Rockville, Maryland 20850