Privacy Practices

Our office is dedicated to protect the privacy rights of our patients and the confidential
information entrusted to us. It is a requirement of this practice that every employee
receive appropriate training and is dedicated to the principal concept that your health
information shall never be compromised. 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 may, from time to time, amend our privacy
policies and practices but will always inform you of any changes that might affect our
obligations and your rights.

Protecting your Healthcare Information
We use and disclose the information we collect from you only as allowed by the Health
Insurance Portability and Accountability Act and the state of Washington. This includes
issues relating to your treatment, payment, and our health care operations. Your
personal health information will never be otherwise given or disclosed to anyone even
family members without your consent or written authorization. You, of course, may give
written authorization for us to disclose your information to anyone you choose, for any
purpose.

Our offices and electronic systems are secure from unauthorized access and our
employees are trained to make certain that the confidentiality, integrity, and access to
your records is always protected. Our privacy policy and practices apply to all former,
current, and future patients, so you can be confident that your protected health
information will never be improperly disclosed or released.

Collecting Protected Healthcare Information (PHI)
We will only request personal information needed to provide our standard of quality
health care, implement payment activities, conduct normal health practice operations,
and comply with the law. This may include your name, address, telephone number(s),
Social Security Number, employment data, medical history, health records, etc. While
most of the information will be collected from you, we may obtain information from third
parties if it is deemed necessary. Regardless of the source, your personal information
will always be protected to the full extent of the law.
Uses and Disclosure of your Protected Healthcare Information
As stated above, we may disclose information as required by law. We are obligated to
provide information to law enforcement and governmental officials under certain
circumstances. We will not use your information for marketing or fund-raising purposes
without your written consent. We may use and/or disclose your health information to
communicate reminders about your appointments including voicemail messages,
answering machines, and postcards unless you direct us otherwise. We will never use,
disclose, sell, or otherwise allow access to your personal, protected information in
exchange for or receipt of financial remuneration.

Any breach in the protection of your personal health information, including unauthorized
acquisition, access, use, or disclosure, will be fully investigated, addressed, and
mitigated as established by the HIPAA Privacy Breach Notification Rule. You have a
right to and will be provided all information relating to any breach involving your
personal PHI.

Treatment: We may disclose your medical information, without your prior approval, to
another dentist or healthcare 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 or from you. 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.
Reminders: We may use or disclose medical information to send you reminders about
your dental care, such as appointment reminders via US Mail, email and telephone. By
providing your email address to us, you agree that you may receive reminders and
breach notifications via email as a possible alternative to US Mail. It is the policy of our
office to leave a message on any voicemail or answering machine that may be attached
to a number that you provide (home, cell or work). If you prefer that we NOT leave a
message to confirm treatment or your appointments, please notify us in writing.
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.
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.
Special protections for SUD records: Substance Use Disorder (SUD) Treatment
records have enhanced protections. They cannot be used in legal proceedings without
your consent or court order.

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
reproductive rights, 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 (in accordance with GINA 2009);
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 as our Patient
You have a right to request copies of your healthcare information; to request copies in a
variety of formats; and to request a list of instances in which we, or our business
associates, have disclosed your protected information for uses other than stated above.
All such requests must be in writing. We may charge for your copies in an amount
allowed by law. If you believe your rights have been violated, we urge you to notify us
immediately. You can also notify the U.S. Department of Health and Human Services.
An expanded, and complete copy of our Statement of Privacy Practices, is available for
your review.

Complants
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 our Privacy Officer to register either a
verbal or written complaint. You may also 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, DC, 20201. You may contact the
Office for Civil Rights’ hotline at 1-800-368-1019. We support your right to privacy of
your medical information. We will not retaliate in any way if you choose to file a
complaint with us or with the US Department of Health and Human Services.