Notice of Privacy Practices

Effective date: October 19, 2016

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. We collect information from you and use it to provide you with quality dental care, and to comply with certain legal requirements. We are required by law to maintain the privacy of your health information, and to give you this Notice of our legal duties, our privacy practices, and your rights. We are required to follow the terms of our most current Notice. When we disclose information to other persons and companies to perform services for us, we will require them to protect your privacy.

How We May Use and Disclose Health Information

Treatment: We may use and disclose your health information to provide dental related treatment or services, to coordinate or manage your health care, or for medical consultations or referrals. We may use and disclose your health information among dentists who are involved in taking care of you at our facilities or with such persons outside our facilities. We may use or share information about you to coordinate the different services you need, such as lab work and x-rays. We may disclose

information about you to people outside our facility who may be involved in your care after you leave, such as family members, your health plan or another provider to arrange a referral or consultation.

Payment: We may use and disclose your health information so that we can receive payment for the treatment and services that were provided. We may share this information with your insurance company or a third party used to process billing information. (As described below, if you pay for your health care in full and out-of-pocket, you may request that we not share your information with your insurance company.) We may contact your insurance company to verify what benefits you are eligible for, to obtain prior authorization, and to tell them about your treatment to make sure that they will pay for your care. We may disclose information to third parties who may be responsible for payment, such as family members, or to bill you. We may disclose information to third parties that help us process payments, such as billing companies, claims processing companies, and collection companies.

Healthcare Operations: We may use and disclose your health information as necessary to operate our practice and make sure that all of our patients receive quality care. We may use health information to evaluate the quality of services that you received, or the performance of our staff in caring for you. We may use health information to improve our performance or to find better ways to provide care. We may use your health information to decide what additional services we should offer and whether new treatments are effective. We may use health information for business planning, or disclose it to attorneys, accountants, consultants and others in order to make sure we are complying with the law.

Certain Marketing Activities: We may use your medical information to forward promotional gifts of nominal value, to communicate with you about products, services and educational programs offered by StarBrite Dental, to communicate with you about your dental case management and for care coordination purposes. We do not sell your health information to any third party for their marketing activities unless you sign an authorization allowing us to do this.

Appointment Reminders and Service Information: We may use or disclose your health information to contact you to provide appointment reminders, or to let you know about other dental services or benefits that may interest to you.

Individuals Involved In Your Care or Payment for Your Care: We may give your health information to people involved in your care, such as family members or friends, unless you ask us not to. We may give your information to someone who helps pay for your care. We may share your information with other health care professionals or disaster-relief organizations, such as the Red Cross, in emergency or disaster-relief situations so they can contact your family or friends or coordinate disaster-relief efforts.

Public Health Activities: We may disclose your health information to public health or legal authorities whose official activities include preventing or controlling disease, injury, or disability. We may use or disclose health information to report reactions to medications, problems with products, or to notify people of recalls of products they may be using. We may use or disclose health information to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease.

Required by Law, Legal Proceedings, Health Oversight Activities, and Law Enforcement: We will disclose your health information when we are required to do so by federal, state and other law. For example, we may be required to report victims of abuse, neglect or domestic violence. We will disclose your health information when ordered in a legal or administrative proceeding, such as a subpoena, discovery request, warrant, summons, or other lawful process. We may disclose health information to a law enforcement official to identify or locate suspects, fugitives, witnesses, victims of crime, or missing persons. We may disclose health information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections and licensure.

Your Written Authorization: Other uses and disclosures of your health information not covered by this Notice, or the laws that govern us, will be made only with your written authorization. These include the sale of your health information and use of your health information for marketing purposes including testimonials. You may revoke your authorization in writing at any time, and we will discontinue future uses and disclosures of your health information for the reasons covered by your authorization. We are unable to take back any disclosures that were already made with your authorization, and we are required to retain the records of the care that we provided to you.

Your Privacy Rights Regarding Your Health Information

Right to Obtain a Copy of This Notice of Privacy Practices: We will post a copy of our current Notice in our dental office and on our website, www.starbritedentalrockville.com . A copy of our current Notice will be available at our registration area or upon request.

Right to See and Copy Your Health Record: You have the right to look at and receive a copy of your dental records. To do so, please contact our Chief Operating Officer. You may be required to make your request in writing. You may request an electronic copy of this information, and we will provide access in the electronic form and format requested if it is readily reproducible in the requested format. If not, we will discuss the issue with you and provide a copy in a readable electronic form and format upon which we mutually agree, depending on the information and our capabilities at the time of the request. If you would like a copy of your dental record, a fee may be charged for the cost of copying or mailing your record (and the electronic media if the request is to provide the information on portable electronic media), as permitted by law. We will provide a copy of your health record usually within 30 days.

Right to Get a List of the Disclosures We Have Made: You have the right to request a list of the disclosures that we have made of your health information. This list is not required to include disclosures made for treatment, payment, and health care operations, and certain other disclosure exceptions. Your request must be in writing and indicate in what form you want the list (for example, on paper, electronically). To request a list of disclosures, please contact the Chief Operating Officer.

Right to Request a Restriction on Certain Uses or Disclosures: You have a right to request a restriction on how we use and disclose your medical information for treatment, payment and health care operations, and to certain family members or friends identified by you who are involved in your care or the payment of your care. We are not required to agree to your request, and will notify you if we are unable to agree. Your request must be in writing and it must (1) describe 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. In some instances, you may choose to pay for a service out of pocket rather than submit a claim to your insurance company. You may request that we not submit your medical information to a health plan or your insurance company, if you, or someone on your behalf, pays for the treatment or service out-of pocket in full. To request this restriction, you must make your request in writing prior to the treatment or service. In your request you must tell us (1) what information you want to restrict and (2) and to what health plan the restriction applies.

We may update this Notice of Privacy Practices from time to time. If we do, a copy of the updated notice will be provided to you.

Person to contact with questions about this Notice: Please contact Nina Kimmel, Chief Operating Officer at nina@starbriteteam.com or 301.200.1103 .