Notice and Acknowledgement of Privacy Practices Please review our Notice of Privacy Practices. If you have any questions call us on (615) 915-6090. Notice of Privacy PracticesTHIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN ACCESS THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US. OUR LEGAL DUTY We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are 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. We reserve the right to make changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make any significant change in our privacy practices we will change this Notice and make the new Notice available 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. USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclose health information about you for your treatment, payment, and healthcare operations. For example: Treatment - We may use or disclose your health information to a physician or other healthcare provider providing treatment to you. Payment - We may use and disclose your health information to obtain payment for services we provide you. Healthcare Operations - We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities. Your Authorization - In addition to our use of your health information for treatment, payment, or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice. To Your Family and Friends - We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so. Persons Involved In Care - We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) family members, your personal representative, or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity, or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgment and our experience with common practices to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information. Marketing Health-Related Services - We will not use your health information for marketing communications without your written authorization. Required by Law - We may use or disclose your health information when we are required to do so by law. Abuse or Neglect - We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence, or the possible victim of other crimes. We may disclose your Health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. National Security - We may disclose to military authorities the health information of Armed Forces Personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances. Appointment Reminders- We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, emails, text messages, or letters). PATIENT RIGHTS Access - You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request, unless we cannot practically do so. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this notice. We will charge a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this notice. If you request copies, we will charge you $0.50 for each page, $10 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure. Disclosure Accounting - You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, healthcare operations and certain other activities, for the past 6 years. If you request this accounting more than once in a 12 month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. Restriction - You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by your agreement (except in an emergency). Alternative Communication - You have the right to request how we communicate with you about your health information by alternative means, or to alternative locations. You must make your request in writing. Your request must specify the alternative means or locations and provide satisfactory explanation for how payments will be handled under the alternative means or location your request. Amendment - You have the right to request we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances. Electronic Notice - If you receive this notice on our web site, via e-mail, or by other electronic means, you are entitled to receive this Notice in written form as well. ADDITIONAL IMPORTANT INFORMATION Health Insurance Portability and Accountability Act or HIPPA does not permit a covered dental practice to allow a business associate access to patient information until the dental practice and the business associate have signed a written agreement containing certain required provisions. This agreement is called a business associate agreement or business associate contract. Covered dental practices must update their existing business associate agreements, which we have done. All business associates must comply with the HIPPA security rules. Associates must also comply with HIPPA privacy rules, and report any breach of unsecured, protected medical history to you, and to the Practice. Our business associates must require the same of any subcontractors. The following use and disclosure requires the patient’s authorization: Many uses of psychotherapy notes Uses and disclosures of protected health information for marketing The sale of protected health information The patient has the right to require restrictions on certain use or disclosure of protected health information, including the right to pay out of pocket for treatment and not have the bill for services be submitted to your health plan or insurance company. You have the right to opt out of receiving fundraising communications. We follow HIPPA guidelines and industry standards to protect patient health information. If there is ever a breach of your protected health information, you will be notified. QUESTIONS AND COMPLAINTS If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative locations, you may complain to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. You have the right to look at or get copies of your health information, with limited exceptions. Michael D. Vaughan, D.D.S. Contact Officer: Jason Taylor / COO Telephone: 615-915-6106 / Fax: 615-915-6091 E-mail: email@example.com Address: 330 Wallace Road, Suite 106, Nashville TN 37211 SubmitDoes the patient have a legal guardian or conservator? Yes No Name of legal guardian or authorized representative?(* required) Name of corporate conservator company if applicable? Please type patient's name:(* required) First Last Today's date:(* required) MM slash DD slash YYYY Do you wish to receive a copy of this Document?(* required) Yes No E-mail address:(* required) CAPTCHAPlease sign(* required)Important: You consent to sign this document electronically.