Privacy Policy

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 our health information. We are also required to make
available to 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 (10/30/2014), 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 made 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 your treatment, payment, and healthcare operations. For Example:

Treatment: We may use or disclose your health information to a dentist, physician or other healthcare provider providing
treatment to you.

Payment: We may use and disclose your health information to obtain payment for your 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 improvement 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 or healthcare operations, 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 revocation 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 disclose 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 notifications of (including
identifying or location) 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 or 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 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 official
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, text messages, emails, postcards, or letters).

PATIENT RIGHTS
Access: You have the right to look at or get copies of your health information, with limited exception. You may request that we
provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably 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. If you request copies, we
will charge you $0 for each page, $0 per hour for staff time to locate and copy your health information, and postage if you want the
copies mailed to You. If you request an alternative format, we will charge a cost-based fee for providing your health information in
that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact the office for a
full explanation of our fee structures.

Disclosure Accounting: You have the right to receive a list of instances 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 June 1, 2008. 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
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 location, and provide satisfactory explanation how payments 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.

Cape Cod Periodontics, P.C. • 244 Willow Street • Yarmouthport, MA. 02675 • 508-375-9090