THIS NOTICE DESCRIBES HOW DENTAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVI6W CAREFULLY.

Safeguarding Your Protected Dental Information
Aesthetic & Family Dental Care is committed to protecting your dental information. In order to provide treatment or to pay for your healthcare, Aesthetic & Family Dental Care will ask for certain health and dental information and that health and dental information will be put into your record.' The record usually contains your symptoms, examination results, x-rays, diagnoses, and treatment. That information, referred to as your dental record, and legally regulated as dental information may be used for a variety of purposes. Aesthetic & Family Dental Care is required to follow the privacy practices described in this Notice, although Aesthetic & Family Dental Care reserves 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 by contacting our office.

How Aesthetic & Family Dental Care May Use and Disclose Your Protected Dental Information:
Aesthetic & Family Dental Care employees will only use your dental information when doing their jobs. For uses beyond what Aesthetic & Family Dental Care normally does. Aesthetic & Family Dental Care must have your written authorization unless the law permits or requires it. The following are some examples of our possible uses and disclosures of your dental information.

Uses and Disclosures Relating to Treatment, Payment, or Health and Dental Care Operations:
For treatment: Aesthetic & Family Dental Care may use or share your dental information to approve or deny treatment and to determine if your dental treatment is appropriate. For example, Aesthetic & Family Dental Care's dental care providers may need to review your treatment plan with your healthcare provider or dental specialty provider for medical necessity or for coordination of care.

To obtain payment:
Aesthetic & Family Dental Care may use and share your dental information in order to bill and collect payment for your dental care services and to determine your eligibility to participate in our services. For example, your dental care provider may send claims for payment of dental services provided to you.

For dental care operations:
Aesthetic & Family Dental Care may use and share your dental information to evaluate the quality of services provided, or to our state or federal auditors.

Other Uses and Disclosures of dental information required or allowed by law:

Information purposes:
Unless you provide us with alternative instructions, Aesthetic & Family Dental Care may send appointment reminders, cancellations and other materials about the program to your home and/or make telephone calls to your home or to other numbers provided to us by you for appointment reminders and/or cancellations.

Required by law:
Aesthetic & Family Dental Care may disclose dental information when a law requires us to do so.

Public health activities:
Aesthetic &Family Dental Care may disclose dental information when required to collect or report information about disease or injury, or to report vital statistics to other divisions in the department and other public health authorities.

Dental oversight activities:
Aesthetic & Family Dental Care may disclose dental information to other divisions in the department and other agencies for oversight activities required by law. Examples of these oversight activities are audits, inspections, investigations, and licensure.

Coroners, Medical Examiners, Funeral Directors and Organ Donations:
Aesthetic & Family Dental Care may disclose dental information relating to a death to coroners, medical examiners or funeral directors, and to authorized organizations relating to organ, eye, or tissue donations or transplants.

Avert threat to health or safety:
In order to avoid a serious threat to health or safety, Aesthetic & Family Dental Care may disclose dental information as necessary to law enforcement or other persons who can reasonably prevent or lessen the threat of harm.

Abuse and Neglect:
Aesthetic & Family Dental Care will disclose your dental information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, domestic violence, or some other crime. Aesthetic & Family Dental Care may disclose your dental information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

Specific government functions:
Aesthetic & Family Dental Care may disclose dental information 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 protection of the President.

Families, friends or others involved in your care:
Aesthetic & Family Dental Care may share your dental information with people as it is directly related to their involvement in your care or payment of your care. Aesthetic & Family Dental Care may also share dental information with people to notify them about your location, general condition or death.

compensation programs that provide callers or visitors who ask for work-related injuries or illnesses without regard to fault.

Patient Directories:
The dental plan under which you are enrolled does not maintain a directory for disclosure to callers or visitors who ask for you by name. You will not be identified to an unknown caller or visitor without authorization.

Lawsuits, Disputes’ and Claims:
If you are involved in a lawsuit, a dispute, or a claim, Aesthetic & Family Dental Care may disclose your dental information in response to a court or administrative order, subpoena, discovery request, investigation or a claim filed on your behalf, or other lawful process.

Law Enforcement:
Aesthetic &,Family Dental Care may disclose your dental information to a law enforcement official for purposes that are required by law or in response to a subpoena.

Request restrictions:
You have a right to request a restriction or limitation on the dental information Aesthetic & Family Dental Care uses or discloses about you. Aesthetic & Family Dental Care will accommodate your request if possible, but is not legally required to agree to the requested restriction. If Aesthetic & Family Dental Care agrees to a restriction, Aesthetic & Family Dental Care will follow it except in emergency situations.

Request Confidential Communications:
You have the right to ask that Aesthetic &Family Dental Care send you information at an alternative address or by alternative means. Aesthetic & Family Dental Care must agree to your
request as long as it is reasonably easy for us to do so.

Inspect and copy:
You have a right to see your dental information upon your written request. If you want copies of your dental information, you may be charged a fee for coping, depending on your circumstances. You have a right to choose what portions of your information you want copied and to have prior information on the cost of copying.

Request amendment:
You may request in writing that Aesthetic & Family Dental Care correct or add to your health record. Aesthetic & Family Dental Care may deny the request if Aesthetic & Family Dental Care determines that the health information is: (1) correct and complete (21 not created by us and/or not Dart of our records: or (31 not permitted to be disclosed; If Aesthetic & Family Dental Care approves the request for amendment, Aesthetic & Family Dental Care will change the dental information and inform you, and will tell others that need to know about the change in the dental information.

Accounting of disclosures:
You have a right to request a list of the disclosures made of your dental information after April 14, 2003. Exceptions are dental information that has been used for treatment or payment. In addition, Aesthetic & Family Dental Care does not have to list disclosures made to you, based on your written authorization, provided for national security, to law enforcement officials or correctional facilities. There will be no charge for up to one such list each year.

Notice: You have the right to receive a paper copy of this Notice and/or an electronic copy by e-mail upon request,

For More Information
If you have questions and would like more information, you may contact the HIPAA Privacy Information Line at 1-410-767-7790.

To Report a Problem about our Privacy Practices:
If you believe your privacy rights have been violated, you may file a complaint.

• You can file a complaint with the Department of Health and Mental Hygiene, Division of Corporate Compliance at 1-866-770-7175.
• You can file a complaint with the Secretary of the U.S. Department of Health and Human Services, Office of Civil Rights. You may call the Department of Health and Mental Hygiene for the contact information.

Aesthetic & Family Dental Care will take no retaliatory action against you if you choose to file a complaint.

Effective Date: This notice is effective on April 14, 2003.