NOTICE OF PRIVACY PRACTICES

This notice describes how dental health information about you may be used and disclosed and how you can get access to this information. Please review the following carefully.

Winslow Dental Group, the office of Drs. Steven S. Maloof and Lance F. Wicklund respect your privacy. We understand that your personal dental health information is very sensitive. We will not disclose your information to others unless you tell us to do so, or unless the law authorizes or requires us to do so. The Law protects the privacy of the dental health information we create and obtain in providing care and services to you. For example, your protected dental health information includes your symptoms, test results, diagnoses, treatment, health information from other providers, and billing and payment information relating to these services. Federal and state law allows us to use and disclose your protected dental health information for purposes of treatment and dental health care operations. State law requires us to obtain your authorization to disclose this information for payment purposes.

Examples of Use and Disclosures of Protected Dental Health Information for Treatment, Payment, and Health Operations:

For treatment:

• Information obtained by a dental assistant, doctor or other member of our dental care team will be recorded in your dental record and used to help decide what care may be right for you.
• We may also provide information to others providing you care. This will help them stay informed about your care.

For payment:

• We request payment from your dental insurance plan. Dental plans need information from us about your dental care. Information provided to dental plans may include your diagnoses, procedures performed, or recommended care.

For dental health care operations:

• We use your dental records to assess quality and improve services.
• We may use and disclose dental records to review the qualifications and performance of our dental health care providers and to train our staff.
• We may contact you to remind you about appointments and give you information about treatment alternatives or other dental health-related benefits and services.
• We may use and disclose your information to conduct or arrange for services, including:
  • dental quality review by your dental health plan;
  • accounting, legal, risk management, and insurance services;
  • audit functions, including fraud and abuse detection and compliance programs.

Your Dental Health Information Rights
The dental health and billing records we create and store are the property of Winslow Dental Group. The protected dental health information in it, however, generally belongs to you. You have a right to:

• Read, review, and copy your dental health information, including your complete chart, radiographs (x rays) and billing records. If you would like a copy of your dental records, please let us know. We may need to charge you a reasonable fee to duplicate and assemble a copy. We have a form available for this type of request.
• Cancel prior authorizations to use or disclose health information by giving us a written revocation. Your revocation does not affect information that has already been released. It also does not affect any action taken before we have it. Sometimes, you cannot cancel an authorization if its purpose was to obtain insurance.

For help with these rights during normal business hours, please contact:
Linda Veach, our Privacy Officer at 206-842-6624.

Our Responsibilities
We are required to:

• Keep your protected dental health information private;
• Give you this Notice; and follow the terms of this Notice.

To Ask for Help or make a complaint
If you have questions, want more information, or want to report a problem about the handling of your protected health information, you may contact: Linda Veach, our Privacy Officer at 206-842-6624. If you believe your privacy rights have been violated, you may discuss your concerns with any staff member. You may also deliver a written complaint to Linda Veach, our Privacy Officer at our dental practice. You may also file a complaint with the U.S. Secretary of Health and Human Services. We respect your right to file a complaint with us or with the U.S. Secretary of Health and Human Services. If you make a complaint, we will not retaliate against you.

Other Disclosures and Uses of Protected Dental Health Information

Notification of Family and Others

• Unless you object, we may release dental health information about you to a friend or family member who is involved in your dental care. We may also give information to someone who helps pay for your care. You have the right to object to this use or disclosure of your information. If you object, we will not use or disclose it.
• To Funeral Directors/Coroners consistent with applicable law to allow them to carry out their duties.
• To Comply with Workers’ Compensation Laws—if you make a workers’ compensation claim.
• To Report Suspected Abuse or Neglect to public authorities.
• For Law Enforcement Purposes such as when we receive a subpoena, court order, or other legal process, or you are the victim of a crime.
• For Disaster Relief Purposes. For example, we may share health information with disaster relief agencies to assist in notification of your condition to family or others.
• In the Course of Judicial/Administrative Proceedings at your request, or as directed by a subpoena or court order.

Other Uses and Disclosures of Protected Dental Health Information

• Uses and disclosures not in this Notice will be made only as allowed or required by law or with your written authorization.

Effective Date:
April 14, 2003