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

The privacy of your medical information is important to us. We understand that your medical information is personal and we are committed to protecting it. We create a record of the care and services you receive. We need this record to provide you with quality care and to comply with certain legal requirements.

Our office has in place appropriate administrative, technical, and physical safeguards to protect the privacy of your Protected Health Information from intentional or unintentional use or disclosure.

All staff members routinely receive privacy training, and will have access to Protected Health Information only on a need-to-know basis, limited to the minimum amount necessary to perform their job functions. In addition, they are required to sign a confidentiality agreement as a condition of employment and to comply with privacy policies and procedures.

We will use reasonable efforts to limit the amount of Protected Health Information that is used, disclosed, or requested, to the minimum degree necessary to accomplish the intended purpose of the use, disclosure or request.

Please note that we are not obligated to provide an atmosphere that is totally free of the possibility that your Protected Health Information may be incidentally overheard by other patients and third parties.

You may request a copy of our Notice of Privacy Practice at any time. This notice took effect April 14, 2003 and will remain in effect until we replace it. We reserve the right to change our privacy practices by changing the terms of the notice, at any time as authorized by law. The changes will be effective immediately upon posting them, and the new notice will be available upon request.

Under federal and state law, we must have your signature on a written, dated Consent form &/or an Authorization form before we will use or disclose your Protective Health Information (i.e.: Individually Identifiable Information, such as names, dates, phone/fax numbers, home/e-mail addresses, social security numbers and demographic data, etc., as well as Super-confidential Information including but not limited to such items pertaining to sexually transmissible diseases, HIV/AIDS records, alcohol and substance abuse diagnosis and treatment records, and psychotherapy and mental health records in accordance with the law).

With your signed consent your Protected Health Information may be used or disclosed by us for:

• treatment, including activities performed by other healthcare providers (i.e.: your general dentist, specialist, etc.) in connection with our rendering orthodontic treatment to you;
  
• payments, including activities to determine your eligibility for insurance coverage/reimbursement/utilization management and pre-authorization of services to third party payers (i.e.: insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.), to spouses, or for collection activities; and/or
  
• healthcare operations including associated business and administrative affairs of this office such as quality assessment, reviewing competence and qualifications, evaluating performance, conducting training, accreditation, certification or licensing activities.

In addition, we may use or disclose your Protected Health Information without your permission, consent, or authorization for the following purposes:

• internally, to all staff members who have any role in your treatment;
  
• to your family members, other relatives and close personal friends, identified or inferred from the circumstances by you, involved in your treatment;
  
• when necessary, in emergencies, to prevent a serious threat to your health and safety or the health and safety of other persons;
  
• to other patients and third parties who may see or overhear incidental disclosures about your treatment, payments, scheduling, etc. (i.e.: sign-in sheets, calling patients by name from the reception room, appointment reminders such as voice mail/answering machine messages, leaving messages with whomever answers your telephone, postcards or letters); and/or
  
• as authorized by federal, state and local laws, including but not limited for public health activities, workers compensation, victims of abuse, neglect, or domestic violence, health oversight activities, disaster relief, judicial and administrative proceedings, law enforcement, court orders, subpoenas, warrants, specialized government functions, research, organ procurement, funeral directors, coroners and medical examiners.

We will not use or disclose your Personal Health Information for any purpose other than treatment, payment and healthcare operations, without your signed Authorization form. We will not condition treatment on whether you sign the Authorization, or not.

Business Associates, and other third parties (if any) that receive your Personal Health Information from us, will be prohibited from re-disclosing it unless required by law or you give express written consent to the re-disclosure.

You have the right to request, in writing, to:

• access, inspect and obtain copies of your Protected Health Information in a timely manner, at a reasonable fee, with limited exceptions;
  
• restrict the use and disclosure of your Protected Health Information (we are not required to agree to these restrictions, but if we do, we will abide by our agreement), except in an emergency;
  
• alternative communication of your Protected Health Information specifying how and where you wish to be contacted; 
  
• amend and modify your Protected Health Information in certain circumstances;
  
• receive an accounting of certain disclosures made by us of your Protected Health Information, for purposes other than treatment, payment, healthcare operations;
  
• revoke prior Consents/Authorization to disclose Protected Health Information, such revocations will be ineffective to the extent that we may have previously acted in reliance on the Consent/Authorization; and/or
  
• you may without risk of retaliation, file a complaint as to any violation by us of your privacy rights with our Privacy Contact Person, Dr. Cohen, or with the United States Secretary of Health & Human Services within 180 days of the violation. Unresolved complaints will be subject to binding arbitration under the rules of the American Arbitration Association with venue in the county where the office is located, with each party to pay their own attorney fees and costs.

If you have any question or concerns about this Notice, or if you want more information about our privacy practices, please contact our Privacy Contact Person, Dr. Cohen.