Perfect Teeth

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NOTICE OF PRIVACY PRACTICES As required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) This notice describes how dental information about you may be used and disclosed and how you can get access to this information. Please review it carefully. A. OUR COMMITMENT TO YOUR PRIVACY Perfect Teeth is dedicated to maintaining the privacy of your individually identifiable health information (IHII). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of protected health information (PHI) that identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in Perfect Teeth concerning your PHI and your Treatment, Payment and Healthcare Operations information (TPO). By federal and state law, we must follow the terms of the Notice of Privacy practices that we have in effect at the time. We realize that these laws are complicated, but we must provide you with the following important information: The terms of this notice apply to all records containing your IIHI that are created or retained by Perfect Teeth. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that Perfect Teeth has created or maintained in the past, and for any of your records that we way create or maintain in the future. Perfect Teeth will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time. B. IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT: Vice President of Regulatory Affairs & HIPAA Compliance/Security Officer Birner Dental Management Services, Incorporated 3801 E. Florida Avenue, #508 Denver, CO 80210 (303) 691-0680 C. WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (IIHI) IN THE FOLLOWING WAYS: The following categories describe the different ways in which we may use and disclose your IIHI. 1. Treatment. Perfect Teeth may use your Health Information to treat you. For example, we may ask you to have laboratory tests (such as tissue tests), and we may use the results to help us reach a diagnosis. We might use your IIHI in order to write a prescription for you, or we might disclose your IIHI to a pharmacy when we order a prescription for you. Many of the people who work for Perfect Teeth including, but not limited to our dentists and hygienists, may use or disclose your IIHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your IIHI to others who may assist in your care, such as a specialist from outside or organization, your spouse, children or your parents. 2. Payment. Perfect Teeth may use and disclose your IIHI in order to bill and collect payment for the services and items you may receive from us.

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