THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT OUR PATIENTS MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Your protected health information (i.e., individually identifiable information, such as names, dates, phone/fax numbers, E-mail addresses, home addresses, social security numbers, and demographic data) may be used or disclosed by us in one or more of the following respects:
· To other health care providers (i.e., your general dentist, oral surgeon, etc.) in connection with rendering your treatment;.
· To third party payers or spouses (i.e., insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of your account (i.e., to determine benefits, dates of payment, etc.);
· To certifying, licensing and accrediting bodies (i.e., the American board of Orthodontics, state dental boards, etc.);
· Internally, to all staff members who have any role in your treatment;
· To other patients and third parties who may see or overhear incidental disclosures about your treatment, scheduling etc.;
· To your family and close friends involved in your treatment; and/or,
· We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you.
Any other uses or disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke.

Under the new privacy rules, you have the right to:
· Request restrictions on the use and disclosure of your protected health information;
· Request confidential communication of your protected health information;
· Inspect and obtain copies of your protected health information through asking us;
· Amend or modify your protected health information in certain circumstances;
· Receive an accounting of certain disclosures made by us of your protected health information; and,
· You may, without risk of retaliation, file a complaint as to any violation by us of your privacy rights with us (by submitting inquiries to our Privacy Contact Person at our office address) or the United States secretary of Health and Human Services (which must be filed within 180 days of the violation).

We have the following duties under the privacy rules:
· By law, to maintain the privacy of health protected information and to provide you with this Privacy Notice setting forth our legal duties and privacy practices with respect to such information;
· To abide by the terms of our Privacy Notice that is currently in effect;
· To advise you of our right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for all protected health information maintained by us, and that if we do so, we will provide you with a copy of the revised Privacy Notice.

Please note that we are not obligated to:
· Honor any request by you to restrict the use or disclosure of your protected health information;
· Amend your protected health information if, for example, it is accurate and complete; or,
· Provide an atmosphere that is totally free of the possibility that your protected health information may be incidentally overheard by other patients and third parties.
This Privacy Notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask our Privacy Contact Person or direct your questions to this person at our office address. Thank you.

Patient/Guardian Acknowledgment

I have acknowledged that I have received and reviewed a copy of this Privacy Notice.

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Patient or Custodial Parent Signature If Patient Is A Minor

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Date Signed
 
 

You may schedule an orthodontic appointment with Dr. William Trepp in his Pasadena, MD office by calling 410.696.4624 or in his Clinton, MD office by calling  301.868.6200. Written inquiries should be mailed to: 3020 Mountain RD, Pasadena, MD 21122, USA or 8918 Woodyard RD, Clinton, MD 20735, USA