Office Privacy Policies

INTRODUCTION: This Notice describes the privacy policies of this dental office. First and foremost, we strive to
maintain confidentiality as far as your dental treatment information. There are times, however, where identifiable
health information must be disclosed to specific entities such as your insurance carrier. Herein we describe how this
confidential dental and health information is used and disclosed and how you can gain access to this confidential
information.

Dental offices are required by applicable federal and state laws to maintain the confidentiality of dental health information generated for patients during the course of treatment. Through recent legislation, dental offices are now required to notify all patients about privacy practices, our legal duties concerning these practices, and your rights concerning your health information. These office privacy policies take effect as of April 14, 2003, and will remain in effect until amended by this office.

We reserve the right to change the privacy practices of this office and the terms of this notice at any time, provided that such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices effective for all health information that we collect and maintain, including prior dental information as well as information gathered before policy changes are determined to be necessary. As changes in our privacy practices are made, we will notify our patients of these changes and make amended Office Privacy Policy statements available upon request.

Our patients are welcome to request copies of our office privacy policies at any time. Please keep this information on file with other documents from this office and check with our receptionist or office manager for any amended versions or changes.

This office uses and discloses health information about you and/or family members for purposes of treatment, payment and dental practice operations. For example:

TREATMENT: We may use or disclose your dental health information to dental colleagues, your physician or other health care providers rendering treatment;

PAYMENT: We may use and disclose your dental treatment information through regular mail, fax or electronic transmission to your dental insurance carrier to obtain payment for services rendered. Limited treatment information may also be disclosed to billing services which assist the office in preparing monthly billing statements.

DENTAL PRACTICE OPERATIONS: We may use and disclose your health information in conjunction with our health care operations, which include quality assessment and improvement activities, reviewing the competence or qualifications of personnel who work in this office, evaluating performance, conducting training programs within the office, accreditation, certification, licensing or credentialing activities. Your health information may also be disclosed to our attorneys and consultants as necessary to respond to any type of investigation or legal action pertaining to the quality of treatment provided to you.

YOUR AUTHORIZATION: In addition to our use of your health information for treatment, payment, or dental practice operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us such an authorization, you have the right to revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.

DISCLOSURE TO FAMILY AND FRIENDS: You have the right for us to disclose your own personal dental health information to you as described in the Patient Rights section of our Privacy Policies. We may also disclose your dental health information to a family member, friend, or other person to the extent necessary to help with your dental care or with payment for your dental care, but only if you agree that we may do so.

PERSONS INVOLVED IN CARE: We may use or disclose dental health information to identify or assist in the identification of you or a family member in conjunction with a forensic investigation. In the event of your incapacity or in emergency circumstances, we will disclose health information based on our professional judgment. In that instance, we will disclose only that information that is directly relevant to the treating entity’s involvement in your health care. We will also use our professional judgment and experience to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, dental supplies, X-rays or other similar forms of health information.

MARKETING: We will not use your dental health information or images of your face and/or teeth for marketing communication without your specific written authorization to do so.

SUBPOENA: We may use or disclose your health information when we are required to do so by law through subpoena.

ABUSE OR NEGLECT: We may disclose dental information of minor patients to appropriate authorities if we have reason to believe that they are possible victims of abuse, neglect or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

NATIONAL SECURITY: We may disclose to military authorities the dental health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials the dental information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose dental information to correctional institutions or law enforcement officials having lawful custody of protected dental information of inmates or patients under certain circumstances.

APPOINTMENT REMINDERS: We may use or disclosure your health information to greater degree than we consider minimally necessary for the purpose of each disclosure.

ACCESS: You have the right to read over or obtain copies of your dental health information, with limited exceptions. Utah Law (R-156-69-502-7) specifies that original records must remain in possession of the treating dentist for seven years, but you may request copies. You may request in person or in writing to obtain access to your dental information. You will be charged a reasonable cost-based fee for expenses such as copies and staff time. You will be asked to sign a brief authorization to obtain copies of your records. For written copies, you may be charged up to $0.75 for each page up to thirty (30) and $0.50 for each page after thirty, a $15.00 administrative fee to locate and copy your health information and postage if you want the copies mailed to you. Radiographs (x-rays) will be duplicated at a reasonable fee related to costs generated by this office to produce copies. Study models (dental casts) will also be duplicated for a reasonable fee related to costs generated by this office to product copies. Study models (dental casts) will also be duplicated for a reasonable fee related to costs of materials and time spent in duplicating the originals. Photographs and slides can also be duplicated at cost. If you prefer, we will prepare a summary or written explanation of your health information for a fee related to the complexity of the summary. You may contact the privacy offices listed at the end of this Notice for a full explanation of our duplication fee structure.

DISCLOSURE FREQUENCY: You have the right to receive a list of instances in which this practice disclosed your dental information for purposes other than treatment, payment, dental practice operations, and certain activities for the six-month period starting April 15, 2003, and at any six-month interval thereafter. If you request this accounting more than once in a twelve-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

RESTRICTION: You have the right to request we place additional restrictions on our use of disclosure of your dental health information. We reserve the right to discuss your request, and we are not required to agree to your additional restrictions. If we agree to abide by your request, however, we may be exempted from this agreement in the event of an emergency.

ALTERNATIVE COMMUNICATION: You have the right to request we communicate with you about your dental health information by alternative means to alternative locations (fax, text, or email, for example). You must make your request in writing. Your request must specify the alternative means or location.

AMENDMENT: You have the right to request we amend your dental health information that has been provided to you. Your request must be in writing, and it must explain why the information should be amended. We reserve the right to deny your request under certain circumstances.

ELECTRONIC NOTICE: If you first reviewed our privacy policies on our websites or by email, you are entitled to receive this Notice in written form upon your request.

If you want additional information about our privacy policies or have questions or concerns, you should contact our privacy officer(s) listed below.

If you believe or are concerned that we may have violated your privacy rights, or your disagree with a decision we make about access to your dental health information or in response to a request you made to ament or restrict the use or disclosure of your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this notice. You may also correspond with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your dental 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.

I have received an explanation and a copy of this office’s notice of privacy practices: