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. THE PRIVACY OF YOUR PERSONAL HEALTH INFORMATION IS IMPORTANT TO US.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires that all health care records and other individually identifiable health information used or disclosed to us in any form, whether electronically, on paper, or orally, to be kept confidential. This federal law gives you, the patient, significant rights to understand and control the manner in which your health information is used. HIPAA provides penalties for covered entities that misuse personal health information (PHI.) As required by law, we have prepared this explanation of the ways that we are require to maintain the privacy of your health information and how we may use and disclose your health information.

OUR OBLIGATIONS:

We are required by law to maintain the privacy of your health information (“Protected Health Information” or “PHI”) and to provide you with this Notice of our legal duties and privacy practices with respect to your Protected Health Information. When we use or disclose your Protected Health Information, we are required to abide by the terms of this Notice (or other notice in effect at the time of the use or disclosure).

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. This notice is to remain in effect until we replace it.

USES AND DISCLOSURES OF HEALTH INFORMATION:

We may use and disclose your medical records/health information for each of the following purposes: treatment, payment, and health care operations.

Treatment: We may use or disclose your health information to a physician, dentist, or other healthcare provider providing (directly or indirectly) treatment to you. Treatment includes providing, coordinating, or managing health care, and included the interaction among one or more health care providers. An example of treatment as related to your PHI would be the use of such information in regards to a health care professional providing hygiene services

Payment: We may use and disclose your PHI to obtain payment for services we

provide to you. Payment includes such activities as obtaining reimbursement for services, confirming coverage, billing or collections, and utilization review. An example of payment as related to your PHI would be the mailing/billing of a bill for your visit to your insurance carrier for reimbursement or payment.

Healthcare Operations: We may use and disclose your health information in regards and reference to our healthcare operations. Healthcare operations include the business aspects of running the practice, such as quality assessment and improvement activities, conducting training, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, accreditation, certification, licensing or credentialing activities. An example would be the conducing of an internal review for quality assessment.

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 other purpose. If you give us an authorization, you may revoke it in writing and we are required to honor and abide by that request. 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.

You have certain rights in regards to your protected health information, which you may exercise through a written request to our Office at the practice address listed below:

Restriction: You have the right to request restrictions on certain uses and disclosures of your protected health information, including those relating to disclosures to family members, relatives, close personal friends, or any other party that identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.

Alternative Communications: You have the right to request or to receive confidential communications of PHI from us by alternate means or at alternate locations.

Access: You have the right to access, inspect, and copy you PHI, with limited exceptions. If requests are made, a reasonable fee may be assessed for the needed staff time to locate and copy health information, printing and shipping costs.

Amendment: You have the right to request an amendment to you PHI. We may deny such a request under certain circumstances.

Disclosure Accounting: You have the right to receive an accounting of disclosures of PHI made outside of treatment, payment, or healthcare operations or based on your previous authorization.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e- mail), you are entitled to obtain a paper copy of this Notice at your request.

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.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

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.

Required by Law: We may use or disclose your PHI when we are required, by law, to do so.

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, postcards, or letters).

QUESTIONS AND COMPLAINTS

If you would like 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, you may complain to 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 PHI. We will not retaliate in any way if you choose to file a complaint with us.

Dr. Peter M. Pellegrini, DDS, MS, P.S.

827 128th St. SW Suite B Everett, WA 98204 425.374.8218