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!

With your consent, the Practice is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services. This notice takes effect 4/15/2003 and will remain in effect until we replace it.

Examples:
Treatment: We may use and disclose your protected health information in order to provide, coordinate or manage your care or related services. We may also disclose your protected health information to other dentists, physicians, healthcare service providers who are now or become involved in taking care of you.

Payment: We may use or disclose your protected health information in order to obtain payment for services we provide to you.

Healthcare Operations: We may use or disclose your health information as needed in connection with our healthcare operations, such as contacting you regarding an appointment, our practice's quality assessment and improvement, development of protocol and clinical guidelines, conducting training programs, credentialing, medical review, legal and insurance services.

Your Health Information Rights
The health record we maintain and billing records are the physical property of the Practice. The information in it, however, belongs to you. You have the right to:

• Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office. We are not required to grant the request but we will comply with any request granted;
• Obtain a paper copy of this Notice of Privacy Practices Health Information ("Notice") by making a request at our office;
• Request that you be allowed to inspect and copy your health record and billing record-you may exercise this right by delivering the request in writing to our office;
• Appeal a denial of access to your protected health information except in certain circumstances;
• Request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office;
• File a statement of disagreement if you're amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information;
• Obtain an accounting of disclosures of your health information as require to be maintained by law by delivering a written request to our office. An accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you or made at your request, or disclosures made to family members or friends in the course of providing care;
• Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office; and,
• Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office.

Our Responsibility
The Practice is required to:

• Maintain the privacy of your health information as information as required by law;
• Provide you with a notice of our duties and privacy practices as to the information we collect and maintain about your;
• Abide by the terms of this Notice;
• Notify you if we cannot accommodate a requested restriction or request; and
• Accommodate your reasonable requests regarding methods to communicate health information with you.

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our "Notice" or by visiting our office and picking up a copy.