HIPAA Statement

Notice of Privacy Practices

This notice is required by the Privacy Regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

Under HIPAA, patients have the right to restrict uses or disclosures of their information for treatment, payment, and healthcare operations purposes.

Treatment

Treatment involves the provision, coordination, or management of dental care, including consultations with third parties or referrals to other healthcare providers. Written consent is required before disclosures outside the practice for treatment purposes, except in emergencies.

Payment

Payment encompasses activities necessary to obtain reimbursement for dental care, including providing your health plan with information about treatments you received. Written consent is required before disclosures for payment purposes.

Healthcare Operations

Healthcare operations include activities necessary for our business operations, such as reviewing treatment and services and evaluating staff performance.

Our Commitment

Densley Dental is committed to protecting the privacy of your medical information. As we provide service to you, we create and store health information (a medical record) that identifies you. We are required to:

• Keep your medical records private and provide you with this notice
• Update our privacy practices and the terms of this notice as needed
• Reserve the right to modify our practices and provide you with an updated notice upon request

Circumstances Requiring Use or Disclosure of Medical Information

1. To share medical data with another provider responsible for your care
2. To share health insurance plan information when filing claims (you may restrict disclosures for services you pay for out of pocket)
3. To disclose information to business associates under confidentiality agreements
4. To share your condition, location, or (in the event of death) status with family members or representatives, with your prior permission unless an emergency applies
5. To provide treatment communications regarding alternatives or health-related products, unless financial remuneration is involved
6. To disclose information to medical examiners for identification or cause-of-death determination
7. To disclose information for active or veteran military personnel as required by military authorities
8. To share data with public health or law enforcement officials for disease, injury, or disability prevention
9. To disclose information to Food and Drug Administration representatives regarding adverse effects from defective products
10. To disclose information when necessary to comply with Workers' Compensation requirements
11. To disclose information in response to a court or administrative order
12. To contact you regarding fundraising activities, with an opt-out option always available
13. To use information for marketing purposes where remuneration is involved or the use constitutes a sale — written authorization is required in other situations
14. To comply with state and federal laws that may be more stringent than HIPAA requirements

Your Rights as a Patient

As a patient of Densley Dental, you have the right to:

1. Request restrictions on uses and disclosures of your health information (must be made in writing and specify what information to limit, whether to limit use, disclosure, or both, and to whom the limits apply)
2. Be notified in the event of a breach of unsecured protected health information
3. Request that we communicate confidential medical information to you by alternative means or at an alternative location (in writing)
4. Request photocopies of your medical records or a copy of this Notice of Privacy Practices
5. Request changes to your health information if it is incomplete or inaccurate (we may refuse if the information is deemed complete and accurate; requests must be made in writing)
6. Receive a list of all instances your medical information has been shared by our office or business associates for the six years prior to your request
7. Request a paper copy of this notice if you originally received it electronically (in writing)

Questions or Complaints

If you have questions about this notice or believe your privacy rights have been violated, please contact us. If concerns remain unresolved, you may submit a written complaint to the US Department of Health and Human Services without fear of retaliation.

• Practice Name: Densley Dental
• Address: 8955 S. Pecos Rd, Ste. 2A, Henderson, NV 89074
• Phone: (702) 212-6641

Effective Date

This Notice shall be effective as of August 1, 2013.