NOTICE OF PRIVACY PRACTICES
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.
UNDERSTANDING YOUR HEALTH INFORMATION
Each time you visit our office, we make a record of your visit in order to manage the care you
receive. We understand that the medical information that is recorded about you and your health
is personal. The confidentiality and privacy of your health information is also protected under both
state and federal law.
This Notice of Privacy Practices describes how this office may use and disclose your information and
the rights that you have regarding your health information.
OUR RESPONSIBILITIES
We are required to (i) maintain the privacy of your medical information as required by law; (ii)
provide you with this Notice of Privacy Practices stating our legal duties and privacy practices with
respect to your medical information; (iii) abide by the terms of this Notice of Privacy Practices; and
(iv) notify you following a breach of your medical information that is not secured in accordance with
certain security standards.
We reserve the right to change the terms of this Notice of Privacy Practices and to make the
provisions of the new Notice of Privacy Practices effective for all medical information that we
maintain. If we change the terms of this Notice of Privacy Practices, the revised Notice of Privacy
Practices will be made available upon request and posted at our office. Copies of the current Notice
of Privacy Practices may be obtained by contacting our Privacy Officer.
How We Will Use or Disclose Your Health Information
Treatment: We will use your health information for treatment. For example, information obtained
by the orthodontist or other members of your healthcare team will be recorded in your record
and used to determine the course of treatment that should work best for you. Your orthodontist
will document in your record his or her expectations of the members of your healthcare team.
Members of your healthcare team will then record the actions they took and their observations, so
the physician will know how you are responding to treatment. We will also provide your physician,
or a subsequent healthcare provider, with copies of various reports that should assist him or her in
treating you.
Payment: We will use your health information for payment. For example, a bill may be sent to you
or your health plan. The information on or accompanying the bill may include information that
identifies you, as well as your diagnosis, procedures, and supplies used.
Health Care Operations: We will use your health information for our regular health care operations.
For example, we may use information in your health record to assess the care and outcome in your
case and others like it. This information will then be used in a continued effort to improve the quality
and effectiveness of the services we provide.
Business Associates: We may enter into contracts with persons or entities known as business
associates that provide services to or perform functions on our behalf. Examples include our
accountants, consultants, and attorneys. We may disclose your health information to our business
associates so they can perform the job we have asked them to do, once they have agreed in writing
to safeguard your information.
Notification: We may use or disclose information to assist in notifying a family member, personal
representative, or another person responsible for your care, of your location, and general condition.
If we are unable to reach your family member or personal representative, then we may leave
a message for them at the phone number that they have provided to us, e.g., on an answering
machine.
Communication With Family: We may disclose to a family member, other relative, close personal
friend or any other person you identify, health information relevant to that person’s involvement in
your care or payment related to your care.
Appointment Reminders: We may contact you to provide appointment reminders or information
about treatment alternatives.
Funeral Directors and Coroners: We may disclose your health information to funeral directors, and to
coroners or medical examiners, to carry out their duties consistent with applicable law.
Organ Procurement Organizations: Consistent with applicable law, we may disclose your health
information to organ procurement organizations or other entities engaged in the procurement,
banking, or transplantation of organs for the purpose of tissue donation and transplant.
Research: We may disclose your health information to researchers when their research has been
approved by an institutional review board that has reviewed the research proposal and established
protocols to ensure the privacy of your health information. We may also disclose your health
information to people preparing to conduct a research project, so long as the health information is
not removed from us. We may also use and disclose your health information to contact you about
the possibility of enrolling in a research study.
Fundraising: We may contact you as part of our fundraising efforts; however, you may opt-out of
receiving such communications.
Food and Drug Administration (FDA): We may disclose to the FDA health information relative to
adverse events with respect to food, supplements, product, and product defects, or post marketing
surveillance information to enable product recalls, repairs, or replacement.
Workers’ Compensation: We may disclose health information to the extent authorized by and to the
extent necessary, to comply with laws relating to workers’ compensation or other similar programs
established by law.
Public Health Activities: As required by law, we may disclose your health information to public
health, or legal authorities, charged with preventing or controlling disease, injury, or disability.
Health Oversight Activities: We may disclose your health information to health oversight agencies
for purposes of legally authorized health oversight activities, such as audits and investigations
necessary for oversight of the health care system and government benefit programs.
Correctional Institution: Should you be an inmate of a correctional institution, we may disclose to
the institution, or agents thereof, health information necessary for your health and the health and
safety of other individuals.
Judicial and Administrative Proceedings: We may disclose your health information in a judicial or
administrative proceeding if the request for the information is through an order from a court or
administrative tribunal. Such information may also be disclosed in response to a subpoena or other
lawful process if certain assurances regarding notice to the individual or a protective order are
provided.
Law Enforcement Purposes / Serious Threat to Health or Safety: We may disclose your health
information to enforcement officials for law enforcement purposes under certain circumstances and
subject to certain conditions. We may also disclose your health information to prevent or lessen a
serious and imminent threat to a person or the public (when the disclosure is made to someone we
believe can prevent or lessen the threat) or to identify or apprehend an escapee or violent criminal.
Victims of Abuse, Neglect, and Domestic Violence: In certain circumstances, we may disclose your
health information to appropriate government authorities if there are allegations of abuse, neglect,
or domestic violence.
Essential Government Functions: We may disclose your health information for certain essential
government functions (e.g., military activity and for national security purposes).
Substance Use Disorder: Some health information we may receive or maintain is subject to
additional federal confidentiality protections under law (42 C.F.R. Part 2), which applies to certain
records related to substance use disorder diagnosis, treatment, or referral. If applicable, this law
generally provides that such information: (i) may not be used or disclosed without your written
consent, except as permitted or required by law; (ii) is subject to stricter limitations on redisclosure
than other health information; and (iii) is protected by additional patient rights and safeguards.
We will comply with all applicable federal laws governing the use and disclosure of substance use
disorder-related information. Nothing in this Notice is intended to reduce the protections provided
by 42 C.F.R. Part 2 where it applies.
The following uses and disclosures will be made only with your authorization: (i) with limited
exceptions, uses and disclosures of your health information for marketing purposes, including
subsidized treatment communications; (ii) disclosures that constitute a sale of your health
information; and (iii) other uses and disclosures not described in this notice. You may revoke your
authorization at any time in writing, except to the extent that we have taken action in reliance on
the use or disclosure indicated in the authorization.
Your Health Information Rights
Although your health record is the physical property of this office, you have the following rights with
respect to your health information:
ï You may request that we not use or disclose your health information for a particular reason
related to treatment, payment, our general healthcare operations, and/or to a particular
family member, other relatives or close personal friend. We ask that such requests be made
in writing on a form provided by us. Although we will consider your request, please be aware
that we are under no obligation to accept it or to abide by it, except as provided below.
ï If you have paid for services out-of-pocket in full, you may request that we not disclose
information related solely to those services to your health plan. We ask that such requests
be made in writing on a form provided by us. We are required to abide by such a request,
except where we are required by law to make a disclosure. We are not required to inform
other providers of such a request, so you should notify any other providers regarding such a
request.
ï You have the right to receive confidential communications from us by alternative means
or at an alternative location. Such a request must be made in writing, and submitted to the
Privacy Officer. We will attempt to accommodate all reasonable requests.
ï You may request to inspect and/or obtain copies of health information about you, which
will be provided to you in the time frames established by law. If we maintain your health
information electronically in a designated record set, you may obtain an electronic copy of
the information. If you request a copy (paper or electronic), we will charge you a reasonable,
cost-based fee.
ï If you believe that any health information in your record is incorrect, or if you believe that
important information is missing, you may request that we correct the existing information
or add the missing information. Such requests must be made in writing, and must provide
a reason to support the amendment. We ask that you use the form provided by us to make
such requests. For a request form, please contact the Privacy Officer.
ï You may request that we provide you with a written accounting of disclosures made by us
during the time period for which you request (not to exceed six years), as required by law.
We ask that such requests be made in writing on a form provided by us. Please note that
accounting does not include all disclosures, e.g., disclosures to carry out treatment, payment,
or healthcare operations and disclosures made to you or your legal representative or
pursuant to an authorization. You will not be charged for your first accounting request in any
12-month period. However, for any requests that you make thereafter, you will be charged a
reasonable, cost-based fee.
ï You have the right to be notified following a breach of your unsecured protected health
information.
You have the right to obtain a paper copy of our Notice of Privacy Practices upon request.
For More Information or to Report a Problem
You have the right to complain to us and to the Secretary of the U.S. Department of Health and
Human Services (HHS) if you believe we have violated your privacy rights. We will not retaliate
against you for filing a complaint.
For more information or to file a complaint with us, contact our Privacy Officer
[EFFECTIVE DATE OF NOTICE 02/16/2026]