Privacy Policy

NOTICE OF PRIVACY PRACTICES: 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.  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 this
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 1/1/2003, 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 the 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 mad the changes.  Before we make a 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 treatment, payment, and healthcare operations. For example: Treatment: We may use
or disclose your health information to obtain payment for services we provide to you.  Payment: We may use and disclose your health
information to obtain payment for services we provide to you. Healthcare Operations:  We may use and disclose your health information in
connection with our healthcare operations.  Healthcare operations include quality assessment and improvements 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 of healthcare operations, only 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 revocations 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 disclosed
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) a family member, 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 practice 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 officials 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, or letters).
PATIENT RIGHTS
Access:  You have the right to look at or get copies of you 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 you 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.  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 instance in which we or our
business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other
activities, for the last 6 years, but not before April 14, 2003.  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 our agreement (except in an emergency). Alternative Communication: You have the right to request that 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 how payment will be handled
under the alternative means or location you request. Amendment:  You have the right to request that 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 or by electronic mail (e-mail), you are entitled to receive this
Notice in written form.
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 of disclosure of your health information or to have us communicate with you by alternative
means or at alternative locations, you may communicate with us using the contact information listed at the end of this Notice.  You also may
submit a written complaint 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 chose to file a complaint with us or with U.S. Department of Health and Human Services.
Contact Officer:  
Smile Dental

11500 University Blvd.
Suite 101
Orlando, Florida    32817

Tel: (407) 737-6464
Fax: (407) 413-8633