Notice of Privacy Practices

As required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act (HIPP A) of 1996.

This notice describes how health information about you (as a patient of this practice) may be used and disclosed, and how you can get access to your individually identifiable health information.

Please review this notice carefully!

A. Our commitment to your privacy

Our practice is dedicated to maintaining the privacy of your Individually Identifiable Health Information (IIHI) In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain our practice concerning your IIHI. By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time.

We realize that these laws are complicated, but we must provide you with the following important information.

• How we may use and disclose your IIHI.
• Your privacy rights in your IIHI.
• Our obligations concerning the use and disclosure of your IIHI.

The terms of this notice apply to all records containing your IIHI that are created or retained by our practice. We reserve the right to revise or amend this notice of privacy practice. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our office in a visible location at all times, and we may request a copy of our most current notice at any time.

B. If your have questions about this notice, please contact

Robbie Patterson 2045 Cecil Ashburn Dr. Stc.203 Huntsville, AL 35802 (256)885-0225

C. We may use and disclose your IIHI in the following ways

1.Treatment
Our practice may use your IIHI to facilitate your treatment. For example, we may ask that you have x-rays or biopsies to enable us to reach a diagnosis of your condition. We might use your IIHI in order to write a prescription for you, or we might disclose your IIHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice including, but not limited to our dentist, hygienist, and dental assistants-may use or disclose your IIHJ in order to treat you or to assist others in your treatment. Additionally, we may disclose your IIHI to others who may assist in your care, such as your spouse, children, or parents. Finally, we may also disclose your IIHI to other health care providers for purposes related to your treatment.

2. Payment
Our practice may use and disclose your IIHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your IIHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your IIHI to bill you directly for services and items. We may disclose your IIHI to other health care providers and entities to assist in their billing and collection efforts information.

3. Health care operations
Our practice may use and disclose your IIHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your IIHI to evaluate the quality of care you received from us or to conduct cost-management and business planning activities for our practice, we may disclose your IIHI to other health care providers and entities to assist in their health care operations.

4. Release of Information to Family/friends
Our practice may release your IIHI to a friend or family member that is involved in your care, or who assists in taking care of you. For example, you may have a family member or friend who will take care of you immediately following treatment. We will disclose your IIHI to the person(s), designated by you, in order for them to adequately care for you during your recovery.

5. Disclosures Required by Law.
Our practice will use and disclose your IIHI when we are required to do so by federal, state, or local law.

D. Use and Disclosure of your IIHI in Certain Special Circumstances.

1. Public Health Risks
Our practice may disclose your IIHI to public health authorities that are authorized by law to collect information for the following purposes:

• Maintaining vital records such as births and deaths.
• Reporting child abuse or neglect.
• Preventing or controlling disease, injury, or disability
• Notifying a person regarding a potential risk for spreading or contracting a disease or condition.
• Reporting reactions 10 drugs or problems with products or devices.
• Notifying individuals if a product or device they may be using has been recalled.
• Notifying appropriate government agencies) and authorities neglect of an adult patient (including domestic violence); however, we will only disclose this information if the patient agrees or we are required or authorized by law to disclose this information.
• Notifying your employer under limited circumstances related primarily to workplace injury or illness or medical surveillance.
  
  

2. Health Oversight Activities.
Our practice may use and disclose your IIHI to a health oversight agency for activities authorized by law. Oversight activities can include investigations, inspections, audits, surveys, licensure, and disciplinary actions; civil, administrative, and criminal procedures or actions, or other activities necessary for the Government to monitor government programs, compliance with civil rights laws, and the health care systems in general.

3. Lawsuits and Similar Proceedings.
Our practice may use and disclose your IIHI in response to a court or administrative order if you are involved in a lawsuit or similar proceeding. We may also disclose your IIHI in response to a discovery request, subpoena, or another lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.

4. Law Enforcement.
We may release your IIHI if asked to do so by a law enforcement official.

• Regarding a crime victim in certain situations, if we are unable to obtain the person's agreement.
• Concerning a death we believe has resulted from criminal conduct.
• Regarding criminal conduct at our office.
• In response to a warrant, summons, court order, subpoena, or similar legal process.
• To identify or locate a suspect, material witness, fugitive, or missing person.
• In an emergency, to report a crime (including the location or victims(s) of the crime, or the deception, identity, or location of the perpetrator).
  
  

5. Serious Threats to Health.
Our practice may use and disclose your IIHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to·a person or organization to help prevent the threat.

6. Military
Our practice may disclose your IIHI if you are a member or the United States or foreign military forces (including veterans) and if required by appropriate authorities.

7. National Security.
Our practice may disclose your IIHI to federal officials for intelligence and National security activities authorized by law. We also may disclose your IIHI to federal officials in order to protect the president, other officials or foreign heads of state, or to conduct investigations.

8. Inmates.
Our practice may disclose your IIHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of law enforcement officials. Disclosure for purposes would be necessary as follows:

• For the institution to provide health care services to you.
• For the safety and security of the institution.
• To protect your health and safety or the health and safety of other individuals.
  
  

9. Worker's Compensation.
Our practice may release your IIHI for workers' compensation and similar programs.

E.Your Rights Regarding Your IIHI.

You have the following rights regarding the IIHI that we maintain about you:

1. Confidential Communications.
You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home rather than at work. In order to request a type of confidential communication, you must make a written request. You must specify the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable request. You do not need to give a reason for your request.

Requested Restrictions. You have the right to request a restriction in our use or disclosure of your IIHI for treatment, payment, or health care operations. Additionally, you have the right to request that we restrict our.disclosure of your IIHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you in order to request a restriction in our use or disclosure of your IIHI, you must make a request in writing. Your request must describe the following in a clear and concise fashion.

• The information you wish restricted.
• Whether you are requesting to limit our practice's use, disclosure, or both.
• To whom you want the limits to apply.
  
  

2. Inspection and Copies.
You have theright to inspect and obtain a copy of the IIHI that may be used to make decisions about you, including patient medical records and billing records, but not including psychotherapy notes, in order to inspect and/or obtain a copy of your 11 HI you must submit your request in writing. Our practice may charge a fee for the costs of copying, mailing, labor, and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.

3. Amendment.
You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit it and the reason supporting it in writing. We may also deny your request if you ask to amend information that is, in our opinion

• Accurate and complete.
• Not part of the IIHI kept by or for our practice.
• Not part of the IIHI that youwould be permitted to inspect and copy.
• Not covered by our practice,unless the individual or entity that created the information is notavailable to amend theinformation.
  
  
  

4. Accounting of Disclosures.
All of our patients have the right to request an accounting of disclosures. The use of your IIHI as part of the routine patient care in our practice is not required to be documented. Examples would be the dentist sharing information with the hygienist or the billing department using your information to file an insurance claim.

5. Right to File a Complain!.
If you believe that your privacy rights have been violated you may file a complaint with our practice or with the secretary of the Department of Health and Human Services. You will not be penalized for filing a complaint with our office.

6. Right to Provide an Authorization for Other Uses and Disclosures.
Our practice will obtain written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law.

Please note: We are required to retain record for your care.

Acknowledgement of Receipt of Notice of Privacy Practices

You May Refuse to Sign This Acknowledgement

have received a copy of this office's Notice of Practices.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.