PLEASE REVIEW IT CAREFULLY.

If you have any questions about this notice, please contact Dr. S. Clarke Woodruff.

WHO WILL FOLLOW THIS NOTICE?

• Any dental care professional authorized to enter information into your chart.
   
• All employees of this office.

OUR PLEDGE REGARDING DENTAL AND MEDICAL INFORMATION:

We understand that dental and medical information about you and your health is personal. We are committed to protecting dental and medical information about you. We create a record of the treatment and services you receive at this office. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all records held in our office of your treatment and care, whether created by this office, or provided by another dental office or your personal doctor.

This notice will tell you about the ways in which we may use and disclose dental and medical information about you. We also describe your rights and certain obligations we have, regarding the use and disclosure of dental and medical information.

We are required by law to:

• make sure that dental and medical information that identifies you is kept private;
   
• give you this notice of our legal duties and privacy practices with respect to dental and medical information about you; and
• follow the terms of this notice that is currently in effect.

HOW WE MAY USE AND DISCLOSE DENTAL AND MEDICAL INFORMATION ABOUT YOU.

The following categories describe different ways that we use and disclose dental and medical information. For each category of uses or disclosures we will explain what we mean and give an example. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

For Treatment: We may use dental and medical information about you to provide you dental treatment or services. We may disclose dental and medical information about you to other dentists who may be involved in a specialized procedure for you. For example, an oral surgeon may need to know if you need to pre medicate prior to a procedure, due to a medical condition.

For Payment: We may use and disclose dental and medical information about you so that the treatment and services you received at this office may be billed to, and payment may be collected from you, an insurance company or a third party. For example, we may need to file a dental claim with your insurance carrier for a procedure you received in this office, so your health plan will pay us or reimburse you for the procedure. We may also tell your insurance carrier about treatment you are going to receive to determine whether your plan will cover the treatment.

For Dental Office Operation: We may use and disclose dental and medical information about you for office operations. These uses and disclosures are necessary to manage the office and to make sure that all of our patients receive quality care. For example, we may use dental and medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine dental and medical information about you with other office patients to decide what additional services this office should offer, what services are not needed, and whether certain new dental treatments are effective. We may also disclose information to other dentists for review and learning purposes. We may also combine dental and medical information we have with other dental offices to compare how we are doing and to see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of dental and medical information so others may use it to study dental care, without learning whom the specific patients are.

Appointment Reminders: We may use and disclose dental and medical information to contact you as a reminder that you have an appointment for treatment at this office.

Treatment Alternatives: We may use and disclose dental and medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services: We may use and disclose dental and medical information to tell you about health-related benefits or services that may be of interest to you.

Individuals Involved in Your Care or Payment for Your Care: We may release dental and medical information about you to a friend or family member who is involved in your dental and medical care. We may also give information to someone who helps pay for your dental care.

As Requested by Law: We will disclose dental and medical information about you when required to do so by federal, state or local law.

Military and Veterans: If you are a member of the armed forces, we may release dental and medical information about you as required by military command authorities.

Workers' Compensation: We may release dental and medical information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks: We may disclose dental and medical information about you for public health activities. These activities general include the following:

• to prevent or control disease, injury or disability;
   
• to report child abuse or neglect;
   
• to report reactions to medications or problems with dental products;
   
• to notify people of recall of dental products that we may be using;
   
• to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and
   
• to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.

Health Oversight Activities: We may disclose dental and medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensors. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose dental and medical information about you in response to a court or administrative order. We may also disclose dental and medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement: We may release dental and medical information if asked to do so by a law enforcement official:

• in response to a court order, subpoena, warrant, summons or similar process;
   
• to identify or locate a suspect, fugitive, material witness or missing person;
   
• about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement;
   
• about a death we believe may be the result of criminal conduct; and
   
• in emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors: We may release dental and medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.

National Security and Intelligence Activities: We may release dental and medical information

about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others: We may disclose dental and medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

YOUR RIGHTS REGARDING DENTAL AND MEDICAL INFORMATION ABOUT YOU.

You have the following rights regarding dental and medical information we maintain about you:

Right to Inspect and Copy: You have the right to inspect and copy dental and medical information that may be used to make decisions about your care. Usually, this includes radiographs, dental and billing records.

To inspect and copy dental and medical information that may be used to make decisions about you, you must submit your request in writing to the office manager. If you request a copy of the information, we will charge a fee for the costs of copying, mailing or other supplies associated with your request.

Right to Amend: If you feel that dental or medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept in our office.

To request an amendment, your request must be made in writing and submitted to Dr. S. Clarke Woodruff. In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

• was not created by us, unless the person who created the information is no longer available to make the amendment;
   
• is not part of the dental or medical information kept by our office;
   
• is not part of the information which you would be permitted to inspect and copy; or
   
• is accurate and complete.

Right to Request Restrictions: You have the right to request a restriction or limitation on the dental and medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the dental and medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a procedure you had.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

To request restrictions, you must make your request in writing to Dr. Woodruff. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse.

Right to Request Confidential Communications: You have the right to request that we communicate with you about dental and medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.

Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice. You may ask our office manager to give you a copy.

Changes to this Notice: We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for dental and medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the office waiting room. The notice will contain on the first page, in the top right-hand corner, the effective date. Each time you visit our office, please check for the current notice in effect. To obtain a paper copy of the most recent notice, please ask our office manager.

Complaints: If you believe your privacy rights have been violated, you may file a complaint with this office or with the Secretary of the Department of Health and Human Services. To file a complaint with this office, contact S. Clarke Woodruff, D.M.D. 800 Main Street, Suite 102, Hellertown, PA 18055. All complaints must be submitted in writing.

Other Uses of Dental and Medical Information: Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with written permission. If you provide us permission to use or disclose dental or medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.