The Health Insurance Portability & Accountability Act of 1996 ("HIPAA") is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal information.

As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

We may use and disclose your medical records only for each of the following purposes:

1. Treatment
2. Payment
3. Health Care Operations

Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would be include teeth cleaning services.

Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company.

Health Care Operations include the business aspects of running our practice, such as conducting quality assessment, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

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. An example of this would be that we may call you about an appointment and, if we are unable to reach you, we may leave a message on your voicemail or with another member of your household.

Parts of our facility have open bay areas and may hinder the COMPLETE privacy concerning patient information. It is our attempt to keep information expressed as confidential as possible.

Photographs and radiographs of conditions and treatment may be used for treating purposes.

Completed orthodontic treatment photos may be displayed for viewing.

Radiographs will be taken as needed at the discretion of the doctor.

The individual whom you have authorized to bring your child in for treatment will have full access to treatment plans and treatment rendered.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing, and we are required to honor and abide by that written request, except to the extent that we may have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by providing a written request to the Privacy Officer within this practice.

1. The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures of family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to requested restriction. If we do not agree to a restriction, we must abide by it unless you agree in writing to remove it.

2. The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.

3. The right to inspect and copy your protected health information

4. The right to amend your protected health information

5. The right to receive an accounting of disclosures of protected health information

6. The right to obtain a paper copy of this notice from us at your first service delivery date.

7. The right to provide a written acknowledgement that you have received a copy of our Notice of Privacy Practices.

We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

This notice is effective as of April 14, 2003, and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you amy request a written copy of a revised Notice of Privacy Practices from this office.

You have recourse if you feel that your privacy protections have been violated. you have the right to file a formal, written complaint with us at the address below, or with the Department of Health and Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filling a complaint.

Please contact us for more information:

Privacy Office
Pediatric Dentistry & Orthodontics
1146 N. New Hope Rd.
Gastonia, NC 28054

For more information about HIPAA or to file a complaint:

The U.S. Dept. of Health and Human Services Office of Civil Rights
200 Independence Ave., S.W.
Washington, D.C. 20201
(202) 619-0257
1-877-696-6775