NOTICE OF PRIVACY PRACTICES

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.

I. Purpose of the Notice
In the course of doing business, we gather protected health information about our patients. We respect the privacy of the patient’s protected health information and understand the importance of keeping this information confidential and secure. We are required by law to maintain the privacy of the patient’s protected health information and to provide individuals with Notice of our legal duties and our privacy practices as to protected health. Because of this, we have implemented policies and procedures in accordance with federal and state laws to protect the patient’s privacy. We are required to abide by terms of the notice of privacy procedures currently in effect. This Notice describes (1) the use and disclosures of protected health information that we may make; (2) the patient’s rights; and (3) our duties with respect to protected health
information.

II. Protected Health Information (referred to as “PHI”)
Except as otherwise provided, the policies and procedures in this Notice apply to your protected health information. “Protected Health Information” means any “individually identifiable health information” that is transmitted by electronic media; (ii) maintained in electronic media; or (iii) transmitted or maintained in any other form or medium. “Protected Health Information” excludes individually identifiable health information in (1) education records covered by the Family Educational Rights and Privacy Act, as amended, 20 U.S.C. 1232g; (2) records described at 20 U.S.C. 1232g(a)(4)(B)(iv); and (3) employment records held by us in our role as employer. “Individually identifiable health information” is information that is a subset of “health information,” including demographic information collected from an individual, and that: (1) Is created or received by a health care provider, health plan, employer, or health care clearinghouse; and (2) relates to the past, present, or future physical or mental health or
condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and (i) that identifies the individual; or (ii) with respect to which there is a reasonable basis to believe the information can
be used to identify the individual. “Health information” means any information, whether oral or recorded in any form or medium, that: (1) Is created or received by a health care provider, health plan, public health authority, employer, life insurer, school, or university, or health care
clearinghouse; and (2) relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual.

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III. Uses and Disclosures of PHI
Uses and Disclosures of PHI
The following categories describe different ways that we are permitted to use and disclose the patient’s PHI with the patient’s explicit approval.
For Treatment. We may use the patient’s PHI for treatment purposes. For example, our dentists, assistants, and other health care personnel involved in the patient’s care may use the patient’s PHI to evaluate the patient’s condition to give the patient the best possible care. We may also disclose the patient’s PHI for treatment purposes. For example, our staff may disclose the patient’s PHI in order to provide and coordinate care and services for the patient, like prescriptions, lab work and X-rays. For Payment. We may use the patient’s PHI for payment purposes. For example, we may use the patient’s PHI to determine the amount that the patient should be billed. We may also disclose the patient’s PHI for payment purposes. For example, we may need to disclose the patient’s PHI to outside parties to bill and to collect payment for treatment that the patient receives. For Health Care Operations. We may use PHI about the patient for health care operations to operate our practice and make sure that all of our patients receive quality care. For example, we may use the patient’s PHI in order to evaluate the quality of health care services that the patient received or to evaluate the performance of the health care professionals who provided health care services to the patient. We may also disclose PHI about the patient for health care operations. For example, we may disclose the patient’s PHI for licensing or auditing purposes. Patient Directories. Unless there is a specific written request from the patient to the contrary, we may use and disclose certain information about the patient in our facility directory. This information may include the patient’s name, location in the facility, general condition, and religious affiliation. We may use PHI to keep track of the location of patients in our facilities. We may disclose this directory information, except for religious affiliation, to people who ask the patient by name. We may disclose all of this information to a member of the clergy, such as a priest or rabbi, even if they do not ask for the patient by name. Individuals Involved In The Patient’s Care Or Payment For The Patient’s Care. Unless there is a specific written request from the patient to the contrary, we may use the patient’s PHI with respect to or disclose the patient’s PHI to persons involved in the patient’s care or payment for that care. This person may be a family member, relative, close personal friend, or other person identified by the patient for this purpose. In addition, we may disclose PHI about the patient to an entity assisting in a disaster relief effort so that the patient’s family can be notified about the patient’s condition, status, and location.

As Required By Law. We may use or disclose PHI about the patient as required by applicable law. Public Health Activities. We may use or disclose PHI about the patient for public health activities such as reporting disease, injury, and vital events to a public health authority authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability.

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Disclosures About Victims Of Abuse, Neglect, Or Domestic Violence. We may disclose PHI about the patient if we reasonably believe the patient to be a victim of abuse, neglect, or domestic violence to a government authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence. Health Oversight Activities. We may use or disclose PHI to a health oversight agency for oversight activities authorized by law. These oversight activities might include, for example, audits, investigations, inspections, licensure, and other activities are necessary for the government to monitor the health care system, government programs, and compliance with civil
rights laws. Judicial And Administrative Proceedings. We may disclose PHI in the course of a judicial or administrative proceeding. We may disclose PHI about the patient in response to a court or administratively ordered subpoena, discovery request, or other lawful process, but only after
efforts have been made to tell the patient about the request. Law Enforcement Purposes. We may disclose PHI for law enforcement purposes to a law
enforcement official, including in response to a court order, subpoena, warrant, summons or similar process; to identify or locate a suspect, fugitive, material witness, or missing person; about the victim of crime under certain limited circumstances; about a death we believe may be the result of criminal conduct; about criminal conduct on our premises; and in emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime. Decedents. We may use or disclose PHI to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death, or other duties, as authorized by law. We may also disclose PHI to funeral directors, consistent with applicable law, as necessary to carry out their duties with respect to the decedent. Organ And Tissue Donation. We may use or disclose PHI to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of cadaveric organs, eye, or tissue for the purpose of facilitating organ, eye, or tissue donation and transplants. Research. Under certain limited circumstances, we may use and disclose PHI about he patient for research purposes. Before we use or disclose PHI for research, the project will have been approved through a research approval process. We may, however, disclose PHI about the patient to people preparing to conduct a research project, for example, to help them look for patients with specific medical needs. The PHI hey review may not leave the medical office. We will generally ask for the patient’s specific permission if the researcher will have access to the patient’s name, address or other information that reveals who the patient’s identity. While the research is in progress, the patient’s access to the patient’s PHI may be limited. To Avert A Serious Threat To Health Or Safety. We may use and disclose PHI about he patient when necessary to prevent a serious threat to the health and safety of the public or a person. Any disclosure, however, would only be to someone able to help prevent the threat or lessen such harm.

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Military and Veterans. If the patient is a member of the armed forces, we may use and disclose PHI about he patient as required by military command authorities under certain regulatory prescribed circumstances. We may also use and disclose PHI about foreign military personnel as required by the appropriate foreign military authority under certain regulatory prescribed circumstances. National Security And Intelligence. We may use or disclose PHI about the patient for national security purposes, such as protecting the President of the United States or foreign heads of state, or for conducting intelligence operations. Inmates. If the patient is an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose PHI about the patient to the correctional institution or law enforcement official. Workers’ Compensation. We may disclose PHI about the patient as authorized by law and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs that provide benefits for work-related injuries or illness. HIV/AIDS Information. Use and disclosure for any PHI about the patient relative to HIV testing, HIV status, or AIDS, is protected by federal and state law. Generally, an authorization must be obtained for the disclosure of such information; however, state law may allow for disclosure of information for public health purposes. Minors. We may disclose PHI about minors to their parents or legal guardians. However, in instances where California law allows minors to consent to their own treatment without parental consent (i.e., HIV testing), information will not be disclosed to a minor’s parents without the minor’s consent unless otherwise specifically allowed under California law. Employers. We may disclose PHI about the patient to the patient’s employer if we provide health care services to the patient as a member of the employers’ workforce or at the request of the employer, and the health care services are provided either (i) to conduct an assessment relating to a medical examination of the workplace or (ii) to determine whether the patient has a workrelated illness or injury and the employer needs such finding to comply with certain of its obligations under federal or state law. In such circumstances, we will give the patient written
notice of such disclosure of information to the patient’s employer. Appointment Reminders And Services. We may use or disclose PHI to provide appointment reminders or test results. Health-Related Products And Services. We may use or disclose PHI to tell the patient about treatment alternative or other health-related benefits and services that may be of interest tot the patient. Fundraising Activities. We may use or disclose PHI about the patient to contact the patient in an effort to raise funds. If the patient does not wish to be contacted as part of our fundraising efforts, the patient may contact in writing our HIPAA Privacy Officer listed in this Notice.

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Other Health-Related Activities. We may use or disclose PHI about the patient to contact the patient in an effort to raise funds. If the patient does not wish to be contacted as part of our fundraising efforts, the patient may contact in writing our HIPAA Privacy Officer listed in this Notice. Other Uses and Disclosures of PHI. Other uses and disclosures of PHI not covered by this Notice or the laws that apply to us will be made only with the Patient’s written permission. If the patient provides us permission to use or disclose PHI, the patient may revoke that permission at any time, except to the extent that we have taken action in reliance on the authorization. Any revocation must be in writing delivered to our HIPAA Privacy Officer.

IV. The Patient’s Rights.
The patient has the following rights with respect to the patient’s PHI: The Right To Request Restrictions. The patient has the right to request a restriction or limitation on uses or disclosures that we make of the patient’s PHI to carry out treatment, payment, or health care operations and uses. The patient also has the right to request a limit on PHI we disclose about the patient to someone who is involved in the patient’s care or in the payment for the patient’s care, like afamily member or friend. In addition, the patient also has the right to request a limit on PHI we use or disclose to notify or assist in the notification of (including identifying or locating) persons responsible for the care of the patient as to the
patient’s location, general condition, or death. We do not have to agree to the requested restriction, but if we do, we may not use or disclose PHI in violation of such restriction, unless the information is needed to provide the patient emergency treatment. To request a restriction, please submit a request in writing to our HIPAA Privacy Officer. The patient’s request must include (1) what information the patient wants to limit; (2) whether the patient wants to limit our use, disclosure or both; and (3) to whom the patient wants the limits to apply (for example, disclosures to the patient’s spouse). An agreed upon restriction may be terminated by the patient or by us, either orally or in writing. If we terminate the restriction, we can only use or disclose PHI we create or obtain after such restriction is terminated. The Right To Request Confidential Communications. The patient has the right tot ask that we send information to the patient to an alternate address (for example, if the patient wants appointment reminders to not be left on an answering machine or if the patient wants information sent tot the patient’s work address rather than the patient’s home address) or by
alternate means (for example, e-mail instead of regular mail). To request PHI be sent to an alternative address or by other means, please submit a request in writing to the HIPAA Privacy Officer. The patient’s request must include (1) the information to which the request applies; and (2) the alternate locations to which the information should be sent or the alternate means to be used.

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The Right To Inspect And Copy. The patient has the right to inspect and receive a copy of the patient’s PHI in the group of records maintained by or for us. These records are the medical records and billing records about he patient maintained by or for us or used, in whole or in part, by or for us to make decisions about he patient. The patient must submit a written request to inspect or copy to the HIPAA Privacy Officer listed in this Notice. After we receive the patient’s written request, we will let the patient know when and how the patient can see or obtain a copy of the patient’s record. If the patient agrees, we will give the patient a summary of the patient’s protected health information. If the patient requests a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies and services associated with the patient’s request. In certain limited situations, we may deny the patient’s request. If we do, we will advise the patient in writing in a timely manner of our reasons for the denial. The Right To Amend. The patient has the right to request that we amend PHI or a record about the patient for as long as we keep the information. To request an amendment, the patient must submit the request in writing along with the patient’s reason for the request to the HIPAA Privacy Officer. We may deny the patient’s 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 the patient’s request in certain other regulatory prescribed circumstances.
The Right To An Accounting Of Disclosures. The patient has the right to request an accounting of disclosures that we have made of the patient’s PHI. This is a list of instances in which we have disclosed PHI about he patient, with certain exceptions specifically defined by law. For example, the accounting will not include disclosures that the patient has specifically authorized or those that are permitted for treatment, payment, or health care operations. To request this accounting of disclosures, the patient must submit a written request to the HIPAA Privacy Officer listed in this Notice. The patient’s request must state a requested time period to be covered by the accounting. The requested time period may not be extend back further than six years before the date of the request and may not include dates before April 14.2003. The first list the patient requests within a 12-month period will be free. For additional lists during the same year, we may charge the patient for the costs of providing the list.
The Right To A Paper Copy Of This Notice. The patient has the right to a paper copy of this
Notice. The patient may ask us to give the patient a paper copy of this Notice at any time. Even if the patient has agreed to receive this Notice by e-mail, the patient is still entitled to a paper copy. To obtain a paper copy of this Notice, please contact the HIPAA Privacy Officer listed in this Notice.

V. Our Duties
We are required by law to maintain the privacy of protected health information and to provide individuals with notice of our legal duties and privacy practices with respect to PHI. We are required to abide by the terms of the Notice currently in effect.

VI. Changes We reserve the right to change the terms of this Notice and our privacy policies at any time. We reserve the right to make the revised or changed Notice provisions effective for all PHI that we maintain. When we make a material change to our policies, we will promptly change this Notice and post a new Notice in the waiting area, as well as have copies available on request.

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VII. Complaints
If the patient believes that the patient’s privacy rights have been violated, the patient may file a written complaint with the HIPAA Privacy Officer. The patients also may send a written complaint to the Office for Civil Rights, U.S. Department of Health and Human Services. We will not retaliate against the patient for filing a complaint about our privacy practices. The patient will not be required to waive this right as a condition of treatment.

VIII. Contact Person
For more information about anything you read in this Notice, please contact our HIPAA Privacy

Officer at (650) 340-6141 or in writing to HIPAA Privacy Officer, A. Ahani, DDS, MD, Inc., 30 N. San Mateo Drive, San Mateo, California, 94401. In addition, any written requests called for under this Notice should also be directed to our HIPAA Privacy Officer.

Notice of Privacy Practices
Copyright © 2002 by JK Health Information Privacy Advisors, a professional corporation, One Embarcadero Center, Fifth Floor, San Francisco, California 94109, TEL: (415) 773-2861, FAX:
(415) 346-8343. All other rights reserved.

Patient Signature: ____________________________________ Date: _____________
(Parent/Guardian Signature if under 18)

Print Full Name: ____________________________________ Date: _____________