This page describes the type of information we gather about you, with whom that information may be shared and the safeguards we have in place to protect it. You have the right to the confidentiality of your medical information and the right to approve or refuse the release of specific information except when the release is required by law. If the practices described in this brochure meet your expectations, there is nothing you need to do. If you prefer that we not share information, we may honor your written request in certain circumstances described below. If you have any questions about this notice, please contact our Privacy Officer at the address or telephone number below.

This notice describes A Perfect Smile, Inc.’s practices regarding the use of your medical information and that of:

    • Any health care professional authorized to enter information into your dental chart or medical record.

    • All departments and units of the clinics or doctor’s offices you may visit.

We understand that medical information about you and your health is personal. Protecting medical information about you is important. We create a record of the care and services you receive. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care held by A Perfect Smile, Inc., whether made by health care professionals or other personnel.
This notice will tell you about the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

The following categories describe different ways that we may use and disclose medical information. For each category of uses or disclosures we will try to give some examples. Not every use or disclosure in a category will be listed.

For Treatment. We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, assistants, hygienists, technicians, pharmacists, or other health care professionals who are involved in taking care of you. For example, a doctor treating you for an impacted wisdom tooth may need to know if you have diabetes because diabetes may slow the healing process. Different health care professionals also may share medical information about you in order to coordinate the different things you need, such as prescriptions, lab work and x-rays. We also may disclose medical information about you to people outside the clinic who may be involved in your dental care after you leave the clinic or that provide services that are part of your care.

For Payment. We may use and disclose medical information about you so that the treatment and services you receive may be billed to and payment may be collected from you, an insurance company or a third party. For example, your insurance may need to know about treatment you received so they will pay us or reimburse you for the treatment. We may also use and disclose medical information about you to obtain prior approval or to determine whether your insurance will cover the treatment.

For Health Care Purposes. We may use and disclose medical information about you for health care purposes. This is necessary to make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also disclose information to doctors, assistants, hygienists, technicians, pharmacists, or other health care personnel for review and learning purposes. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.

Appointment Reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment.

Treatment Alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

Health-Related Benefits and Services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.

Business Associates. We may disclose your medical information to our Business Associates to carry out treatment, payment or health care operations. For example, we may disclose medical information about you to a company who bills insurance companies on our behalf to enable that company to help us obtain payment for services we provide.

As Required By Law. We will disclose medical information about you when required to do so by federal, state or local law. We may release medical information about you to authorized federal officials for national security and intelligence activities.

To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Unless you object in writing, we may use or disclose your medical information in the following circumstances:

Individuals Involved in Your Care or Payment for Your Care. We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may also tell your family or friends your condition and that you are in the hospital. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort, or other community or public information provider, so that your family can be notified about your condition, status and location.

Workers' Compensation. We may release medical information about you for workers' compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks. We may disclose medical information about you for public health activities. These activities generally include the following:

Health Oversight Activities. We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes. We may disclose medical information about you in response to a subpoena, discovery request, or other lawful order from a court.

Law Enforcement. We may release medical information if asked to do so by a law enforcement official as part of law enforcement activities; in investigations of criminal conduct or of victims of crime; in response to court orders; in emergency circumstances; or when required to do so by law. For example, we may disclose medical information about you to comply with laws that require the reporting of certain kinds of wounds or other physical injuries.

Coroners and Medical Examiners. We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.

Protective Services for the President, National Security and Intelligence Activities. We may release medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations, or for intelligence, counterintelligence, and other national security activities authorized by law.

Emergency Circumstances and Disaster Relief. We may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified of your location and general condition. Even if you object, we may still share the medical information about you, if necessary for the emergency circumstances.

Inmates. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution.

You have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy. You have the right to inspect and copy medical information that may be used to make decisions about your care.

To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing to our Privacy Officer at the address on the last page. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that the denial be reviewed. Another licensed health care professional chosen by A Perfect Smile, Inc. will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome of the review.

Right to Amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept.

To request an amendment, your request must be made in writing and submitted to our Privacy Officer. In addition, you must provide a reason that supports your request.

We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that:

We will tell you in writing the reasons for the denial and describe your rights to give us a written statement disagreeing with the denial. If we accept your request to amend the information, we will make reasonable efforts to inform others of the amendment, including persons you name who have received information about you and who need the amendment.

Right to an Accounting of Disclosures. You have the right to request an "accounting of disclosures." This is a list of disclosures we have made of medical information about you. This Accounting of Disclosures does not include disclosures made for your treatment, billing and collection of payment for your treatment, health care operations, made to or requested by you, or that you authorized, occurring as a byproduct of permitted uses and disclosures, made to individuals involved in your care, or for other purposes described in the above subsections.

To request an accounting of disclosures, you must submit your request in writing to our Privacy Officer. You must state the time period, which may not be longer than six (6) years and may not include dates before March 01, 2006. The first accounting request within a twelve (12) month period will be free of charge. For additional accountings, we may charge you for the costs of providing the accounting. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend.

We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.

To request restrictions, you must make your request in writing to our Privacy Officer at the address below. In your request, you must tell us (1) 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.

Right to Request How We Communicate With You. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail.

To request confidential communications, you must make your request in writing to our Privacy Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.

To obtain a paper copy of this notice, please hit the "PRINT" button on your web browser, or alternatively you may request a paper copy of this notice by writing to our Privacy Officer at the address below.

We reserve the right to change this notice. We reserve the right to make the updated or changed notice effective for medical information we already have about you as well as any information we receive in the future. When we change the notice, we will post an announcement that the notice has been changed and post a copy of the updated notice. The notice will contain on the first page, in the top right-hand corner, the effective date and update date.

Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, thereafter we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.

If you believe your privacy rights have been violated, you may file a complaint with A Perfect Smile, Inc. or with the Secretary of the Department of Health and Human Services. To file a complaint with A Perfect Smile, Inc., contact our Privacy Officer at the address and phone number listed below. All complaints must be submitted in writing.

A Perfect Smile, Inc.                                                                                     Attn: Privacy Officer
11358 Miramar Parkway
Miramar, Florida 33025
954-442-0006

Secretary, Health and Human Services
Office of Civil Rights, Medical Privacy
Complaint Division, US Department of HHS
200 Independence Avenue, SW,
HHH Building, Room 509H
Washington, DC 20201

© 2006 A Perfect Smile. All rights reserved.