Notice of Privacy Practices 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. You Have the Right to Receive this Notice: You have the right to receive a paper copy of this Notice and/or an electronic copy by e-mail upon request. How to Complain About Our Privacy Practices: If you think we may have violated your privacy rights, or you disagree with a decision we have made about access to your Personal Health Information (PHI), you may file a complaint with the person listed below. You also may file a written complaint with the Secretary of the U.S. Department of Health and Human Services at 200 Independence Avenue S.W., Washington D.C., 20201 or call 1-877-696-6775. We will take no retaliatory action against you if you make such complaints. Contact Person for Information or to Submit a Complaint: If you have questions about this Notice or any complaints about our privacy practices, please send your written request for a standard complaint form to: Attention: Privacy Officer Dr. Paul E. Ziman, Practice Limited to Orthodontics 1964 Rahncliff Court, Eagan, MN 55122 Or call our office with any questions: (612) 332-0130 or (507) 663-1669 Effective Date: This notice is effective on April 14, 2003. Our Duty to Safeguard Your Protected Health Information: Individually identifiable information about your past, present or future health or condition, the provision of health care to you, or payment for health care is considered “Protected Health Information” (PHI). We are required to extend certain protections to your PHI, and to give you this Notice about our privacy practices that explains how, when and why we may use or disclose your PHI. Except in specified circumstances, we must use or disclose only the minimum necessary PHI to accomplish the intended purpose of the use or disclosure. We are required to follow the privacy practices described in this Notice though we reserve the right to change our privacy practices and the terms of this Notice at any time. You may request a copy of the new Notice from our business office in writing at: Dr. Paul E. Ziman, Practice Limited to Orthodontics 1964 Rahncliff Court Eagan, MN 55122 or by calling our office at (612) 332-0130 or (507) 663-1669. How We May Use and Disclose Your Protected Health Information: We use and disclose Personal Health Information for a variety of reasons. We have a limited right to use and/or disclose your PHI for purposes of treatment, payment and for health care operations. For uses beyond that, we must have your written authorization unless the law permits or requires us to make the use or disclosure without your authorization. If we disclose your PHI to an outside entity in order for that entity to perform a function on our behalf, we must have in place an agreement from the outside entity that will extend the same degree of privacy protection to your information that we must apply to your PHI. However, the law provides that we are permitted to make some uses/disclosures without your consent or authorization. The following describes and offers examples of our potential uses/disclosures of your PHI. Uses and Disclosures Relating to Treatment, Payment or Health Care Operations: Generally we may use or disclose your PHI as follows: For Treatment: We may disclose your PHI to doctors, nurses and other health care personnel who are involved in providing your health care. For example, your PHI will be shared among members of your treatment team, or with our staff. Your PHI may also be shared with outside entities performing ancillary services relating to your treatment , such as lab work or x-rays, or for consultation services , or other health care agencies involved in the provision or coordination of your care. To Obtain Payment: We may use/disclose your PHI in order to bill and collect payment for your orthodontic services. For example, we may release your information to your insurance carrier to obtain payment for services provided. We may also release your PHI to a collection agency if this action is necessary to collect payment for services provided. For Health Care Operations: We may use/disclose your PHI in the course of operating our practice. For example, we may take your photograph for diagnostic purposes, use your PHI in evaluating the quality of services provided, or disclose your PHI to our accountant or attorney for audit purposes. Since we are an integrated system, we may disclose your PHI to designated staff in each of our offices. Release of your information may be necessary to your dental office or a specialist (such as an oral surgeon or periodontist) in order to provide your care. Appointment Reminders: Unless you provide us with alternative instructions, we may send appointment reminders and/or similar materials to your home. Uses and Disclosures of PHI Requiring Authorization: For uses and disclosures beyond treatment, payment and operations purposes, we are required to have your written authorization, unless the use or disclosure falls within one of the exceptions described below. Authorizations can be revoked at any time to stop future uses/disclosures except to the extent that we have already undertaken an action in reliance upon your authorization. Uses and Disclosures of PHI of Your Health Records Not Requiring Consent or Authorization: The law provides that we may use/disclose your PHI from your records without consent or authorization in the following circumstances:  When required by law: We may disclose PHI when law requires that we report information about suspected abuse, neglect or domestic violence, or relating to suspected criminal activity, or in response to a court order. We must also disclose PHI to authorities that monitor compliance with these privacy requirements. For public health activities: We may disclose PHI when we are required to collect information about disease or injury, or to report vital statistics to the public health authority. For health oversight activities: We may disclose PHI to an agency responsible for monitoring the health care system for such purposes as reporting or investigation of unusual incidents. Relating to decedents: We may disclose PHI related to death to coroners, medical examiners or funeral directors, and to organ procurement organizations relating to organ, eye, tissue donations or transplants. To avert threat to health or safety: In order to avoid a serious threat to health or safety, we may disclose PHI as necessary to law enforcement or other persons who can reasonably prevent or lessen the threat of harm. For specific government functions: We may disclose PHI of military personnel and veterans in certain situations, to correctional facilities in certain situations, to government benefit programs relating to eligibility and enrollment, and for national security reasons, such as the protection of the President. Uses and Disclosures of PHI from Alcohol and Other Drug Records Not Requiring Consent or Authorization: The law provides that we may use/disclose your PHI from alcohol and other drug records without consent or authorization in the following circumstances: When required by law: We may disclose PHI when a law requires that we report information about suspected child abuse and neglect, or when a crime has been committed on the office premises or against office staff or personnel, or in response to a court order. Relating to decedents: We may disclose PHI relating to an individual’s death if state or federal law requires the information for collection of vital statistics or inquiry into cause of death. For research, audit or evaluation purposes: In certain circumstances, we may disclose PHI for research, audit or evaluation purposes. To avert threat to health or safety: In order to avoid a serious threat to health or safety, we may disclose to law enforcement when a threat is made to commit a crime on the office premises or against office staff or personnel. Uses and Disclosures: Requiring You to Have an Opportunity to Object In the following situations, we may disclose a limited amount of your PHI if we inform you about the disclosure in advance and you do not object, as long as the disclosure is not otherwise prohibited by law. Patient Directories: Your name, location and general condition may be put into our patient directory for disclosure to callers or visitors who ask for you by name. To families, friends or others involved in your care: We may share with these people information directly related to their involvement in your care, or payment for your care. We may also share PHI with these people to notify them about your location, general condition or death. Your Rights Regarding Your Protected Health Information: You have the following rights relating to your PHI: To request restrictions on uses/disclosures: You have the right to ask that we limit how we use or disclose your PHI. We will consider your request, but are not legally bound to agree to the restriction. To the extent that we do agree to any restrictions on our use/disclosure of your PHI, we will put the agreement in writing and abide by it except in emergency situations. We cannot agree to limit uses/disclosures that are required by law. To choose how we contact you: You have the right to ask that we send you information at an alternative address or by an alternative means. We must agree to your request as long as it is reasonably easy for us to do so. To inspect and request a copy of your PHI: Unless your access to your records is restricted for clear and documented treatment reasons, you have a right to see your protected health information upon your written request. We will respond to your request within 30 days. If we deny your access, we will give you written reasons for the denial and explain any right to have the denial reviewed. If you want copies of your PHI, a charge for copying may be imposed, depending on your circumstances. You have a right to choose which portions of your information you want copied and to have prior information on the cost of copying. Request amendment of your PHI: If you believe that there is a mistake or missing information in our record of your PHI, you may request in writing that we correct or add to the record. We will respond within 60 days of receiving your request. We may deny the request if we determine that the PHI is: (1) correct and complete; (2) not created by us and/or not part of our records, or; (3) not permitted to be disclosed. Any denial will state the reasons for denial and explain your rights to have the request and denial, along with any statement in response that you provide, appended to your PHI. If we approve the request for amendment, we will change the PHI and so inform you, and tell others that need to know about the change in your PHI. To find out what disclosures have been made: You have a right to get a list of when, to whom, for what purpose, and what content of your PHI has been released other than instances of disclosure: for treatment, payment and operations; to you, your family, or the facility directory; or pursuant to your written authorization. The list also will not include any disclosures for national security purposes, to law enforcement officials or correctional facilities, or disclosures made before April 2003. We will respond to your written request for such a list within 60 days of receiving it. Your request can relate to disclosures going as far back at six years. There will be no charge for up to one such list per year. There may be a charge for more frequent requests. I acknowledge that a copy of this notice has been provided to me for my review: __________________________________________________________ Patient/Guardian Signature Date