Notice of Privacy Practices

Effective Date of Notice: September 10, 2014

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.

If you have any questions about this Notice, please contact us at: (954) 217-9200

WE WILL COMPLY WITH THIS NOTICE
This Notice describes the privacy practices of INDIAN TRACE DENTAL, our providers, our pharmacies, and any third parties that help us manage Protected Health Information. In general, we may use and disclose your health information to coordinate and oversee your dental treatment, pay your dental claims, and assist in health care operations as described in this Notice.

OUR COMMITMENT TO PROTECT YOUR HEALTH INFORMATION
We believe that information about you and your health, whether it is in verbal, written, or electronic formal is personal and should be carefully safeguarded. We are committed to protecting your personal health information. We (or the third parties that assist us) maintain a record of all health care provided by or paid for by the practice of INDIAN TRACE DENTAL This Notice applies to all of your health information that we maintain. Please be aware that health care providers or pharmacies not associated with us, such as other doctors, dentists, hospitals, or outside Pharmacies have their own policies regarding their use and disclosure of your health information created in their offices. You should consult their Notice of Privacy Practices for information about how they may use and disclose your health information.

This Notice informs you about the ways we may use and disclose your health information. This Notice also describes your privacy rights, along with the obligations that we have regarding the use and disclosure of your health information. Federal medical privacy law requires us to:

• Make sure your health information is kept private;
• Give you this Notice of our Privacy Practices with respect to your health information; and
• Follow the terms of this Notice.

HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION

. Telemarketing. We do not sell your personal health information or disclose it to companies that wish to sell you their products. We must have your written permission (called an “authorization”) to use and disclose your health information, except for the uses and disclosures described below. We do not sell your health information to anyone or disclose your health information to other companies who may want to sell their products to you (e.g. catalog or telemarketing firms), Additionally, Florida law may require that we obtain your specific prior authorization to use and disclose certain health information, such as behavioral health, substance abuse and HIV/AIDS information.

. You and Your Personal Representative. We may disclose your health information to you or your personal representative (an individual who has the legal right to act on your behalf).

. Others Involved in Your Care. We may share your health information with family members or friends who are directly involved in your dental care, or the payment of your dental care, when you are present and have given us verbal or written permission. We will not discuss your health information with your family or friends if you are not present unless you have given us your permission or we believe it is in your best interest. Our health professionals will exercise their professional judgment in determining when friends and family members may receive health information (e.g., a family member picking up a prescription from the pharmacy for a sick individual).

. Treatment. We may use your health information or disclose it to third parties to aid with your dental treatment. We may disclose health information about you to doctors, nurses, pharmacists, technicians, dental students, or other persons who are involved in taking care of you. For example, the Doctor may give your health information to another physician for follow up services, or to a physician or other healthcare provider for oral surgery or other treatment.

. Payment. We may use your health information or disclose it to third parties in order to obtain payment for the services that we provide to you. For example, we may discuss your health information with your insurer to determine whether your health plan will cover the treatment.

. Health Care Operations. We will use and disclose your health information for general administrative and managerial functions, and activities such as quality assessment and improvement, providing educational training programs for dental, nursing, dental, and other health and non-health care professions, accreditation, certification, and licensing. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; training of students, including imaging of treatment sessions; defense of legal matters; business planning; and outside storage of our records.

. Appointment Reminders and Health Related Benefits and Services. We may use and disclose your health information to remind you about appointments for dental care in our offices.

. Research. We may use or disclose your health information to third parties for research purposes when an Institutional Review Board has determined that such disclosure is appropriate without your permission.

. Marketing. We may also engage in face-to-face communication with you about alternative treatment options available to you, or communicate with you about the health related services available to you through any public government institution, but not to a private organization in which we may obtain benefits for the referral. We may also give you promotional gifts of nominal value as a method of marketing our services. Before we can use your health information for other marketing purposes or receive payment for sending marketing communications, we must first obtain your written authorization.

. As Required by Law. We will disclose your health information to third parties when required to do so by federal, state or local law. For example, we may share your health information when required to do so by state workers’ compensation law, the Department of Health and Human Services, or state regulatory officials.

. To avert a serious Threat to Health or Safety. We may use and disclose your health information to third
parties when it is necessary to prevent a serious threat to your health and safety or to the health and safety of the public or another person. Any disclosure, however, would only be to someone able to assist in preventing the potential harm.

. Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose your health information in
response to a court or administrative order. We may also disclose your health information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute.

. Public Policy Matters. We may use or disclose your health information in certain limited instances for matters involving the public welfare, such as:

• For public health risks (e.g., prevention or control of disease, reporting births and deaths, reporting abuse and neglect) or for research purposes when there are sufficient privacy protections in place.
• To a health oversight agency for activities authorized by law (e.g., audits, investigations, inspections, and
  licensure necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws);
• To law enforcement officials (in response to a court order, subpoena, warrant, summons or similar process or to report certain kinds of crimes) and to national security officials under certain limited circumstances;
• To a funeral director, coroner, or medical examiner to permit them to carry out their Duties;
• To facilitate organ donation and specified research purposes, so long as certain safety measures are in place to protect your privacy;
• Employers and Plan Sponsors. In order for you to be enrolled in a health plan, we may share limited information with your employer or other organizations that help pay for your health coverage. However, if your employer or another organization that helps pay for your health coverage asks for specific health information, we will not share your health information unless they first obtain your written authorization.

. Business Associates. We hire third parties to provide us with various services that are necessary for our health plan to function. Before we share your health information with these companies, we will have a written contract with them in which they promise to protect the privacy of your health information.

. Fundraising. We may use and disclose your health information for fundraising communications; however, you have the right to opt out of receiving future fundraising communications.

. Other Uses and Disclosures of PHI. We have no plans to use or disclose your health information for purposes other than those provided for above or as otherwise permitted or required by law. If you provide us an authorization to use or disclose your health information to third parties, you may revoke the authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose your health information for the reasons covered by your written authorization. Please remember that we are unable to take back any disclosures we have already made with your authorization.

YOU’RE RIGHTS REGARDING YOUR HEALTH INFORMATION

You have several rights regarding your health information and we will respect your right to exercise them. If you wish to exercise your rights, you must submit a written request on a standard form we will provide to you. You can obtain this form by calling our office at(954) 217-9200or by writing to us at ADDRESS: 46 Indian Trace, Weston, Fl 33326

. Right to Inspect And Copy. You have the right to inspect and copy your health information that we maintain. Usually this includes your dental, medical and billing records. If you request a copy of the information, we may charge a fee for our costs of providing the copy. We may deny your request to inspect and copy in very Imited circumstances. If we deny your request to access your health information, we will explain why the request was denied and whether you have the right to a further review of the denial.

. Right to Request Amendments. If you feel that your health information is incorrect or incomplete, you may ask
us to correct the information. You must include with your request an explanation of how and why your health
information needs to be corrected. We may deny your request for correction in certain limited circumstances. If we agree to your request for correction, we will take reasonable steps to inform others of the correction.

. Right to Request an Accounting of Disclosures. You have the right to request an accounting of disclosures. This is a list of certain disclosures of your health information that we have made to third parties. This is limited to disclosures during the last three years. If you request this accounting more than once in any 12 month period, we may charge you for the cost of responding to these additional requests. Your request should tell us how you want the list (e.g., on paper, via e-mail, or on a disk).

. Right to Request Additional Restrictions. You have the right to request a restriction on how we use or disclose your health information to third parties for your dental treatment, payment of your dental claims, or management of our health care operations. You also have the right to request a limitation on how we disclose your health information to those involved in your care or the payment for your care, such as a family member or friend. For instance, you can request that we not disclose information to your spouse or children concerning a sensitive surgical procedure or a disease you have suffered. Please note that under federal law, we are generally not required to agree to your request. However, if you pay the full cost of your treatment without any contribution from a health plan, your health care provider will agree upon your request not to share your treatment with your health plan for payment or health

Care operations purposes.
. Right to Request Confidential Communications. We communicate to you information about your health care treatment and payment. If you feel that our communicating with you may endanger you, you may request that we communicate with you using a reasonable alternative means or location. For example, you can ask that we contact you only at work, by e-mail, or by mail at a specified address (such as a P.O. Box, rather than your home mailing address). We will accommodate all reasonable requests.

. Right to a Paper Copy of This Notice. You have the right to receive a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice, or by writing to us at the address listed above.

. Right to Receive Notification of a Breach of Your Health Information. You will receive timely notification if there is a breach of your unsecured health information,

CHANGES TO THIS NOTICE
We have the right to change the terms of this Notice. We also have the right to make these changes apply to
health information we already have about you, as well as any we receive or create in the future. We will post a copy of the most current Notice in the practice of INDIAN TRACE DENTAL, and have a copy available for you to request and take with you. Please look at the top right-hand corner of the Notice to determine the Notice’s effective date.

QUESTIONS OR COMPLAINTS
If you have questions about your privacy rights described in this Notice, or if you believe that
We may have violated your privacy rights, please contact us at:

INDIAN TRACE DENTAL
ADDRESS: 46 Indian Trace, Weston, Fl 33326
PHONE:(954) 217-9200 FAX: (954) 217-9500

You may also file a written complaint with us, as well as with the Department of Health and Human Services. We
support your right to protect your health information. We will not penalize you or retaliate against you for filing
a complaint.