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

Your  protected  health  information  (i.e.,  individually  identifiable  information,  such  as  names,  dates,   phone/fax  numbers,  email  addresses,  home  addresses,  social  security  numbers,  and  demographic  data)   may  be  used  or  disclosed  by  us  in  one  or  more  of  the  following  respects:

• To  other  health  care  providers  (i.e.,  your  general  dentist,  oral  surgeon,  etc.)  in  connection  with  our   rendering  orthodontic  treatment  to  you  (i.e.,  to  determine  the  results  of  cleanings,  surgery,  etc.);
• To  third  party  payors  or  spouses  (i.e.,  insurance  companies,  employers  with  direct  reimbursement,   administrators  of  flexible  spending  accounts,  electronic  insurance  claims,  etc.)  in  order  to  obtain   payment  of  your  account  (i.e.,  to  determine  benefits,  dates  of  payment,  etc.);
• To  certifying,  licensing  and  accrediting  bodies  (i.e.,  the  American  Board  of  Orthodontics,  state  dental   boards,  etc.)  in  connection  with  obtaining  certification,  licensure  or  accreditation;
• Internally,  to  all  staff  members  who  have  any  role  in  your  treatment; •  To  other  patients  and  third  parties  who  may  see  or  overhear  incidental  disclosures  about  your   treatment,  scheduling,  etc.;
• To  your  family,  parent(s),  guardian(s)  and  close  friends  involved  in  your  treatment;  and/or,
• We  may  contact  you  (via  phone,  email,  text  messaging,  etc.)  to  provide  appointment  reminders  or   information  about  treatment, treatment  alternatives,  notices  regarding  insurance,  declined  credit  card   payments,  expired  credit  cards,  NSF  notices  or  other  health-­‐related  benefits  and  services  that  may  be  of   interest  to  you.

Any  other  uses  or  disclosures  of  your  protected  health  information  will  be  made  only  after  obtaining   your  written  authorization,  which  you  have  the  right  to  revoke.

Under  the  new  privacy  rules,  you  have  the  right  to:

•  Request  restrictions  on  the  use  and  disclosure  of  your  protected  health  information;
• Request  confidential  communication  of  your  protected  health  information; •  Inspect  and  obtain  copies  of  your  protected  health  information  through  asking  us;
• Amend  or  modify  your  protected  health  information  in  certain  circumstances;
• Receive  an  accounting  of  certain  disclosures  made  by  us  of  your  protected  health  information;  and,
• You  may,  without  risk  of  retaliation,  file  a  complaint  as  to  any  violation  by  us  of  your  privacy  rights   with  us  (by  submitting  inquiries  to  our  Privacy  Contact  Person  at  our  office  address)  or  the  United  States   Secretary  of  Health  and  Human  Services  (which  must  be  filed  within  180  days  of  the  violation).

We  have  the  following  duties  under  the  privacy  rules:

• By  law,  to  maintain  the  privacy  of  protected  health  information  and  to  provide  you  with  this  notice   setting  forth  our  legal  duties  and  privacy  practices  with  respect  to  such  information;
• To  abide  by  the  terms  of  our  Privacy  Notice  that  is  currently  in  effect;
• To  advise  you  of  our  right  to  change  the  terms  of  this  Privacy  Notice  and  to  make  the  new  notice   provisions  effective  for  all  protected  health  information  maintained  by  us,  and  that  if  we  do  so,  we  will provide  you  with  a  copy  of  the  revised  Privacy  Notice.

Please  note  that  we  are  not  obligated  to:

• Honor  any request  by  you  to  restrict  the  use  or  disclosure  of  your  protected  health  information;
• Amend  your  protected  health  information  if,  for  example,  it  is  accurate  and  complete;  or,
• Provide  an  atmosphere  that  is  totally  free  of  the  possibility  that  your  protected  health  information   may  be  incidentally  overheard  by  other  patients  and  third  parties.

This  privacy  notice  is  effective  as  of  the  date  of  your  signature.  If  you  have  any  questions  about  the   information  in  this  Notice,  please  email info@mayokeeffeortho.com, ask  for  our  Privacy  Contact  Person  and  direct  your  questions  to  this   person  at  our  office  address.  Thank  you.

rev.  7/2013