Notice of Privacy Practices

Effective Date April 2003

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

1. Purpose: Dr. Rouse, his associates and employees follow the privacy practices describes in this Notice. We maintain your health information in records that are kept in a confidential manner, as required by law. We must use and disclose or share your health information as necessary for treatment, payment, and health care operations to provide you with quality health care.

2. What are treatment payment and health care operations? Treatment includes sharing information among health care providers involved in your care. For example, your health care provider may share information about your condition with the pharmacist to discuss medications. We may use your health information as required by your insurer or HMO to obtain payment for your treatment. We may use and disclose your health information to improve the quality of care and for education and training purposes of dental students, residents and private practitioners.

3. How will we use and disclose your health information? Your health information may be used for the following purposes unless you ask for restrictions on a specific use or disclosure:

• Family members or close friends involved in your care or payment for treatment.
• Disaster relief agency if you are involved in a disaster relief effort
• To inform you of treatment alternatives or benefits or services related to your health.
• Appointment Reminders
• Public health activities, including disease prevention, injury or disability; reporting reactions to medications or product problems; notification or recalls; infectious disease control; notifying government authorities of suspected abuse, neglect, or domestic violence.
• Health oversight activities, such as audits, inspections, investigations and licensure.
• Law enforcement.
• Coroners, medical examiners, and funeral directors.
• Organ and tissue donations.
• To prevent a serious threat to health or safety.
• To military command authorities if you are a member of the armed forces or a member of a foreign military authority.
• National security and intelligence activities to authorized persons to conduct special investigations.
• Workers compensations. Your medical information regarding benefits for work-related injuries and illnesses may be released as appropriate.
• Alcohol and drug abuse information has special privacy protections. We will not disclose any information identifying an individual as being a patient or provide any health information relating to the patient¹s substance abuse treatment unless the patients consents in writing or as required by law.
• To carry out health care treatment, payment, and operations functions through business associates, such as to install a new computer system.

4. Your authorization is required for other disclosures. Except as described above, we will not use or disclose your medical information, unless you allow us in writing to do so.

5. You have rights regarding your health information. You have the following rights regarding your medical information, if you request.

• Right to request restriction. You may request limitations on your health information that we use or disclose for health care treatment, payment, or operations, although we are not required to comply with your request. For example, you may ask us not to disclose that you have had a particular procedure. We will release the information if necessary for emergency treatment.
• Right to confidential communications. You may request communications of your health information in a certain way or at a certain location, but you must tell us how or where you wish to be contacted.
• Right to insect and copy. You have the right to review and obtain a copy of your medical or health record. We may charge a fee for copying, mailing, and supplies. Under limited circumstances, your request may be denied; you may request review of the denial by another licensed health care professional chosen by us. We will comply with the outcome of the review.
• Right to request amendment. If you believe that the health information we have about you is incorrect or incomplete, you may request an amendment in writing. We are not required to accept the amendment.
• Right to accounting disclosures. You may request a list of the disclosures of your health information that have been made to person or entities for disclosures unrelated to health care treatment, payment, or operations within the past six (6) years but not prior to April 14, 2003. After the first request, there may be a charge.
• Right to a copy of this notice. You may request a paper copy of this notice at any time, even if you have been provided with a copy before.

6. Requirements regarding this notice. We are required by law to provide you with this notice. We will comply with this notice for as long as it is in effect. We may change this notice, and these changes will be effective for health information we have about you, as well as any information we receive in the future.

7. Complaints. If you believe your privacy rights have been violated, you may file a complaint with the Secretary of the United States Department of Health and Human Services. We will not penalize or retaliate against you in any way for making a complaint.