Notice of Privacy Practices

Orthodontic Specialty Services, Inc.

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Our Responsibilities

We are required by law to maintain the privacy of protected health information (PHI), to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information.

We must follow the privacy practices described in this Notice while it is in effect. This Notice takes effect September 23, 2013 and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law, and to make new Notice provisions effective for all protected health information that we maintain. When we make a significant change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at our practice location, and will provide copies of the new Notice upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

How We May Use and Disclose Health Information About You

We may use and disclose your PHI for different purposes, including treatment, payment, and health care operations.

Treatment

We may use and disclose your PHI for your treatment. For example, we may disclose your PHI to a specialist providing treatment to you.

Payment

We may use and disclose your PHI to obtain reimbursement for the treatment and services we provide to you from another entity involved with your care. Payment activities include billing, collections, claims management, and determinations of eligibility and coverage. We may obtain payment from you, your insurance company, or another third party. For example, we may send claims to your dental plan containing certain health information.

Healthcare Operations

We may use and disclose your PHI in connection with our healthcare operations. These activities include quality assessment and improvement activities, conducting training programs, and licensing activities.

Individuals Involved in Your Care or Payment

We may disclose your PHI to your family, friends, or other individuals identified by you when they are involved in your care or in payment for your care. If a person has authority by law to make health care decisions for you, we will treat that person as your personal representative.

Disaster Relief

We may use or disclose your PHI to assist in disaster relief efforts.

Required by Law

We may use or disclose your PHI when required to do so by law.

Public Health Activities

We may disclose your PHI for public health activities, including disclosures to:

• Prevent or control disease, injury, or disability

• Report child abuse or neglect

• Report reactions to medications or problems with products or devices

• Notify a person of a recall, repair, or replacement of products or devices

• Notify a person who may have been exposed to a disease or condition

• Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence

National Security

We may disclose PHI to military authorities for Armed Forces personnel under certain circumstances. We may also disclose PHI to authorized federal officials for lawful intelligence, counterintelligence, and other national security activities.

Correctional Institutions

We may disclose PHI to correctional institutions or law enforcement officials having lawful custody of an inmate or patient.

Secretary of HHS

We will disclose your PHI to the Secretary of the U.S. Department of Health and Human Services when required to investigate or determine compliance with HIPAA.

Worker’s Compensation

We may disclose your PHI as authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs.

Law Enforcement

We may disclose your PHI for law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order.

Health Oversight Activities

We may disclose PHI to oversight agencies for activities authorized by law, including audits, investigations, inspections, and licensure activities.

Judicial and Administrative Proceedings

If you are involved in a lawsuit or dispute, we may disclose your PHI in response to a court or administrative order, subpoena, discovery request, or other lawful process.

Research

We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has established protocols to ensure the privacy of your information.

Coroners, Medical Examiners, and Funeral Directors

We may release PHI to a coroner or medical examiner to identify a deceased person or determine cause of death. We may also disclose PHI to funeral directors as necessary.

Fundraising

We may contact you regarding sponsored activities or fundraising programs. If you do not wish to receive such information, you may opt out.

Other Uses and Disclosures of PHI

Your authorization is required for most uses and disclosures of psychotherapy notes, marketing purposes, and the sale of PHI.

We will obtain your written authorization before using or disclosing your PHI for purposes other than those described in this Notice (or as otherwise required or permitted by law).

You may revoke your authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization.

Your Health Information Rights

You have the following rights regarding your health information:

Access

You have the right to look at or get copies of your health information, with limited exceptions. Requests must be made in writing. We may charge a reasonable cost-based fee for copies.

If your health information is maintained electronically, you may request an electronic copy in the format you request if readily producible.

If access is denied, you may request a review of the denial.

Disclosure Accounting

You have the right to receive an accounting of disclosures of your health information, with certain exceptions. The first accounting in a 12-month period is free. Additional requests within that period may incur a reasonable fee.

Right to Request Restrictions

You have the right to request restrictions on certain uses or disclosures of your PHI. We are not required to agree to your request, except where the disclosure is to a health plan for payment or healthcare operations and you have paid in full out-of-pocket.

Alternative Communication

You may request that we communicate with you using alternative means or at alternative locations. Requests must be in writing and include an explanation of how payment will be handled.

Amendment

You have the right to request an amendment to your health information. Requests must be in writing and explain why the amendment is needed. If we deny your request, we will provide a written explanation.

Right to Notification of a Breach

You will receive notifications of breaches of your unsecured protected health information as required by law.

Electronic Notice

You may receive a paper copy of this Notice upon request, even if you have agreed to receive it electronically.

Questions or Complaints

If you would like more information about our privacy practices or have questions or concerns, please contact us.

If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S. Department of Health and Human Services. We will provide you with the address to file a complaint with HHS upon request.

We support your right to the privacy of your health information and will not retaliate against you for filing a complaint.

Contact Information

Privacy Official: Jennifer Klepper
Telephone: 260-497-0497
Fax: 260-489-4853
Address: 1120 East Dupont Road, Fort Wayne, IN 46825
Email: jenk@ossfw.com