THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
CAREFULLY.

We understand that medical information about you and your health is personal "Protected Health
Information" ("PHI") and we are committed to protecting your medical information. PHI includes
individually identifiable information about your past, present, or future health or condition, the
provision of health care to you, or payment for such health care. We use and disclose PHI about you for
treatment, payment, and healthcare operations.
Treatment:
We may disclose PHI to your insurance provider, our dentist(s), and other dental care providers for
treatment purposes. For example, your dentist may wish to provide a dental service to you but first
seeks information from your insurance provider as to whether the service has been previously provided.
Payment:
We disclose your PHI in order to fulfill our duty to check your coverage, determine your benefits, and
secure payment for services provided to you. For example, we use your PHI in order to request process
of your claims by your insurance provider.
Health Care Operations:
We disclose your PHI as a part of certain operations, such as quality improvement. For example, we may
use your PHI to evaluate the quality of dental services that were performed.
We may be asked by the sponsor of your health plan to provide your PHI to the sponsor. If we are asked
to do so, we intend to honor such requests unless we are prohibited by law.
We may use or disclose your PHI without your authorization for several other reasons. Subject to certain
requirements, we may give out PHI without your authorization for public health purposes, auditing
purposes, research studies, and emergencies. We provide PHI when otherwise required by law, such as
for law enforcement in specific circumstances, or for judicial or administrative proceedings. In any other
situation, we will ask for your written authorization before using or disclosing your PHI. If you choose to
sign an authorization to allow disclosure of your PHI, you can later revoke that authorization to stop any
future uses and disclosures (other than for treatment, payment, and health care operations).
We may change our policies at any time. Before we make a significant change in our policies, we will
change our notice and send the new notice to you. You can also request a copy of our notice at any time.
Individual Rights:
In most cases, you have the right to view or get a copy of your PHI. You also have the right to receive a
list of instances where we have disclosed your PHI without your written authorization for reasons other
than treatment, payment, or health care operations. If you believe that information in your record is
incorrect or if important information is missing, you have the right to request that we correct the
existing information or add the missing information. You may request in writing that we not use or
disclose your PHI for treatment, payment, and health care operations except when specifically
authorized by you, when required by law, or in emergency circumstances. We will consider your request
but are not legally required to accept it. You also have the right to receive confidential communications
of PHI by alternative means or at alternative locations, if you clearly state that disclosure of all or part of
your PHI could endanger you.
Complaints:
If you are concerned that we have violated your privacy rights, or you disagree with a decision we have
made about access to your records, you may contact the address listed below. You may also send a
written complaint to the U.S. Department of Health and Human Services. Customer Service can provide
you with the appropriate address upon request.
Our Legal Duty:
We are required by law to protect the privacy of your information, provide this notice about our
information practices, and follow the information practices that are described in this notice. If you wish
to inspect your records, receive a listing of disclosures, or correct or add to the information in your
record, or if you have any questions, complaints, or concerns, please contact our office.