This notice describes how medical information about you may be used and disclosed, and how you can get access to this information. Please review carefully.

Your protected health information (i.e., individually identifiable information, such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used or disclosed by us in one or more of the following respects:

• To other health care providers (e.g., your general dentist, oral surgeon, etc.) in connection with our rendering orthodontic treatment to you (e.g., to determine the results of cleanings, surgery, etc.).
• To third party payers or spouses (e.g., insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of your account (e.g., to determine benefits, dates of payment, etc.).
• To certifying, licensing and accrediting bodies (e.g., the American Board of Orthodontics, state dental boards, etc.) in connection with obtaining certification, licensure or accreditation.
• Internally, to all staff members who have any role in treatment.
• To other patients and third parties who may see or overhear incidental disclosures about your treatment, scheduling, etc.
• To your family and close friends involved in your treatment.
• We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Any other uses or disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke.

Under the new privacy rules, you have the right to:

• Request restrictions on the use and disclosure of your protected health information.
• Request confidential communication of your protected health information.
• Inspect and obtain copies of your protected health information by asking us.
• Amend or modify your protected health information in certain circumstances.
• Receive an accounting of certain disclosures made by us of your protected health information.
• File a complaint without risk of retaliation regarding any privacy rights violations by contacting our Privacy Contact Person or the U.S. Secretary of Health and Human Services (within 180 days of the violation).

We have the following duties under the privacy rules:

• By law, we must maintain the privacy of protected health information and provide you with this notice detailing our legal duties and privacy practices.
• We are required to abide by the terms of this Privacy Notice currently in effect.
• We must advise you of your right to change the terms of this Privacy Notice and apply new provisions to all protected health information we maintain. If changes are made, we will provide you with a copy of the revised notice.

Please note that we are not obligated to:

• We are not obligated to honor requests to restrict the use or disclosure of your protected health information.
• We are not required to amend your protected health information if it is accurate and complete.
• We cannot guarantee an environment completely free from the possibility of incidental disclosure of your protected health information.

This Privacy Notice is effective as of the date of your signature.

If you have any questions about the information in this notice, please ask for your Privacy Contact Person or direct your questions to this person at our office address.

Thank you.