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NOTICE OF PRIVACY PRACTICES

Effective Date:September 16, 2013

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. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.

CONTACT INFORMATION

For more information about our privacy practices, to discuss questions or concerns, or to get additional copies of this notice, please contact our Privacy Officer. Katey Lopez

Title: Privacy Officer Telephone: (715) 842–3704 Fax: (715) 842-4207

Email Address: ddsmshill@michaelshilldentistry.com

OUR LEGAL DUTY

We are required by law to protect the privacy of your protected health

information (“medical information”). We are also required to send you this notice

about our privacy practices, our legal duties, and your rights concerning your

medical information.

We must follow the privacy practices that are described in this notice while it is

in effect. This notice takes effect on the date set forth at the top of this page, and

will remain in effect unless we replace it.

We reserve the right to change our privacy practices and the terms of this

notice at any time, provided such changes are permitted by applicable law. We

reserve the right to make any change in our privacy practices and the new terms

of our notice applicable to all medical information we maintain, including medical

information we created or received before we made the change.

We may amend the terms of this notice at any time. If we make a material

change to our policy practices, we will provide to you the revised notice. Any

revised notice will be effective for all health information that we maintain. The

effective date of a revised notice will be noted. A copy of the current notice in

effect will be available in our facility and on our website if applicable. You may

request a copy of the current notice at any time.

We collect and maintain oral, written and electronic information to administer

our business and to provide products, services and information of importance to

our patients. We maintain physical, electronic and procedural security safeguards

in the handling and maintenance of our patients’ medical information, in

accordance with applicable state and federal standards, to protect against risks

such as loss, destruction or misuse.

USES AND DISCLOSURES OF YOUR MEDICAL INFORMATION

Treatment: We may disclose your medical information, without your prior

approval, to another dentist, a physician or other health care provider working

in our facility or otherwise providing you treatment for the purpose of evaluating

your health, diagnosing medical conditions, and providing treatment. For example,

your health information may be disclosed to an oral surgeon to determine whether

surgical intervention is needed.

Payment: We provide dental services. Your medical information may be used

to seek payment from your insurance plan. For example, your insurance plan may

request and receive information on dates that you received services at our facility

in order to allow your employer to verify and process your insurance claim.

Health Care Operations: We may use and disclose your medical information,

without your prior approval, for health care operations. Health care operations

include:

• healthcare quality assessment and improvement activities;

• reviewing and evaluating dental care provider performance, qualifications

and competence, health care training programs, provider accreditation,

certification, licensing and credentialing activities;

• conducting or arranging for medical reviews, audits, and legal services,

including fraud and abuse detection and prevention; and

• business planning, development, management, and general administration,

including customer service, complaint resolutions and billing, de-identifying

medical information, and creating limited data sets for health care operations,

public health activities, and research.

We may disclose your medical information to another dental or medical provider

or to your health plan subject to federal privacy protection laws, as long as the

provider or plan has or had a relationship with you and the medical information

is for that provider’s or plan’s health care quality assessment and improvement

activities, competence and qualification evaluation and review activities, or fraud

and abuse detection and prevention.

Your Authorization: You (or your legal personal representative) may give us

written authorization to use your medical information or to disclose it to anyone for

any purpose. Once you give us authorization to release your medical information,

we cannot guarantee that the person to whom the information is provided

will not disclose the information. You may take back or “revoke” your written

authorization at any time in writing, except if we have already acted based on your

authorization. Your revocation will not affect any use or disclosure permitted by

your authorization while it was in effect. Unless you give us a written authorization,

we will not use or disclose your medical information for any purpose other than

those described in this notice. We will obtain your authorization prior to using your

medical information for marketing, fundraising purposes or for commercial use.

Once authorized, you may opt out of any of these communications.

Family, Friends, and Others Involved in Your Care or Payment for Care: We

may disclose your medical information to a family member, friend or any other

person you involve in your care or payment for your health care. We will disclose

only the medical information that is relevant to the person’s involvement.

We may use or disclose your name, location, and general condition to notify,

or to assist an appropriate public or private agency to locate and notify, a person

responsible for your care in appropriate situations, such as a medical emergency

or during disaster relief efforts.

We will provide you with an opportunity to object to these disclosures, unless

you are not present or are incapacitated or it is an emergency or disaster relief

situation. In those situations, we will use our professional judgment to determine

whether disclosing your medical information is in your best interest under the

circumstances.

Health-Related Products and Services: We may use your medical information

to communicate with you about health-related products, benefits, services,

payment for those products and services, and treatment alternatives.

Reminders: We may use or disclose medical information to send you reminders

about your dental care, such as appointment reminders.

Plan Sponsors: If your dental insurance coverage is through an employer’s

sponsored group dental plan, we may share summary health information with the

plan sponsor.

Public Health and Benefit Activities: We may use and disclose your medical

information, without your permission, when required by law, and when authorized

by law for the following kinds of public health and public benefit activities:

• for public health, including to report disease and vital statistics, child abuse,

and adult abuse, neglect or domestic violence;

• to avert a serious and imminent threat to health or safety;

• for health care oversight, such as activities of state insurance commissioners,

licensing and peer review authorities, and fraud prevention agencies;

• for research;

• in response to court and administrative orders and other lawful process;

• to law enforcement officials with regard to crime victims and criminal

activities;

• to coroners, medical examiners, funeral directors, and organ procurement

organizations;

• to the military, to federal officials for lawful intelligence, counterintelligence,

and national security activities, and to correctional institutions and law

enforcement regarding persons in lawful custody; and

• as authorized by state worker’s compensation laws.

If a use or disclosure of health information described above in this notice is

prohibited or materially limited by other laws that apply to us, it is our intent to

meet the requirements of the more stringent law.

Business Associates: We may disclose your medical information to our

business associates that perform functions on our behalf or provide us with

services if the information is necessary for such functions or services. Our

business associates are required, under contract with us, to protect the privacy of

your information and are not allowed to use or disclose any information other than

as specified in our contract.

Data Breach Notification Purposes: We may use your contact information to

provide legally-required notices of unauthorized acquisition, access, or disclosure

of your health information.

Additional Restrictions on Use and Disclosure: Certain federal and state

laws may require special privacy protections that restrict the use and disclosure

of certain health information, including highly confidential information about you.

“Highly confidential information” may include confidential information under Federal

laws governing alcohol and drug abuse information and genetic information as

well as state laws that often protect the following types of information:

1. HIV/AIDS;

2. Mental health;

3. Genetic tests;

4. Alcohol and drug abuse;

5. Sexually transmitted diseases and reproductive health information; and

6. Child or adult abuse or neglect, including sexual assault.

YOUR RIGHTS

Access: You have the right to examine and to receive a copy of your medical

information, with limited exceptions. We will use the format you request unless

we cannot practicably do so. You should submit your request in writing to our

Privacy Officer.

We may charge you reasonable, cost-based fees for a copy of your medical

information, for mailing the copy to you, and for preparing any summary or

explanation of your medical information you request. Contact our Privacy Officer

for information about our fees.

Disclosure Accounting: You have the right to a list of instances in which we

disclose your medical information for purposes other than treatment, payment,

health care operations, as authorized by you, and for certain other activities.

You should submit your request to our Privacy Officer. We will provide you with

information about each accountable disclosure that we made during the period for

which you request the accounting, except we are not obligated to account for a

disclosure that occurred more than 6 years before the date of your request.

Amendment: You have the right to request that we amend your medical

information. You should submit your request in writing to our Privacy Officer.

We may deny your request only for certain reasons. If we deny your request, we

will provide you a written explanation. If we deny your request, you may have a

statement of your disagreement added to your medical information. If we accept

your request, we will make your amendment part of your medical information and

use reasonable efforts to inform others of the amendment who we know may

have and rely on the unamended information to your detriment, as well as persons

you want to receive the amendment.

Restriction: You have the right to request that we restrict our use or disclosure

of your medical information for treatment, payment or health care operations, or

with family, friends or others you identify. Except in limited circumstances, we

are not required to agree to your request. But if we do agree, we will abide by

our agreement, except in a medical emergency or as required or authorized by

law. You should submit your request to our Privacy Officer. Except as otherwise

required by law, we must agree to a restriction request if:

1. except as otherwise required by law, the disclosure is to a health plan for

purposes of carrying out payment or health care operations (and not for purposes

of carrying out treatment); and

2. the medical information pertains solely to a health care item or service for

which the health care provider involved has been paid out of pocket in full by the

patient.

Confidential Communication: You have the right to request that we

communicate with you about your medical information in confidence by means

or to locations that you specify. You should submit your request in writing to our

Privacy Officer.

Breach Notification: You have the right to receive notice of a breach of

your unsecured medical information. Breach may be delayed or not provided

if so required by a law enforcement official. You may request that notice be

provided by electronic mail. If you are deceased and there is a breach of your

medical information, the notice will be provided to your next of kin or personal

representatives if we know the identity and address of such individual(s).

Electronic Notice: If you receive this notice on our web site or by electronic

mail (e-mail), you are entitled to receive this notice in written form. Please contact

our Privacy Officer to obtain this notice in written form.

COMPLAINTS

If you are concerned that we may have violated your privacy rights, or you

disagree with a decision we made about access to your medical information,

about amending your medical information, about restricting our use or disclosure

of your medical information, or about how we communicate with you about your

medical information (including a breach notice communication), you may contact

to our Privacy Officer.

You also may submit a written complaint to the Office for Civil Rights of the

United States Department of Health and Human Services, 200 Independence

Avenue, SW, Room 509F, Washington, D.C. 20201. You may contact the Office for

Civil Rights’ Hotline at 1-800-368-1019.

We support your right to the privacy of your medical information. We will not

retaliate in any way if you choose to file a complaint with us or with the U.S.

Department of Health And Social Services.

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