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LEGAL INFORMATION & DISCLAIMERS

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

This Notice applies to the information and records we have about your health, health status, and the health
care and services you receive at this office. 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 April 14, 2012, and
will remain in effect until we replace it.

If you have any questions about this Notice, complaints, or should you need to contact Beverly Drive Dental Care’s
Privacy Officer to comply with any provision of this Notice, please contact: Beverly Drive Dental Care’s Privacy
Officer, C/o Beverly Drive Dental Care, Inc., 1125 South Beverly Drive, Beverly Hills, CA 90035, Phone: (310) 277-
7645. E-mail: mvazquezmd@yahoo.com

Organizations covered by Joint Notice:

Beverly Drive Dental Care, Inc.
Beverly Drive Dental Care Plan

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

For Treatment We may use your health information to provide you with medical treatment or services. We may
disclose health information about you to doctors, dental assistants, technicians, office staff or other personnel who
are involved in taking care of you and your health.

For example, your doctor may be performing a tooth extraction and may need to know if you have other health
problems that could complicate your treatment. The doctor may use your health history to decide what treatment
is best for you. The doctor may also tell another doctor about your condition so that doctor can help determine the
most appropriate care for you.

Different personnel in our office may share information about you and disclose information to people who do not
work in our office in order to coordinate your care, such as phoning in prescriptions to your pharmacy, scheduling
lab work and ordering x-rays. Family members and other health care providers may be part of your medical care
outside this office and may require information about you that we have.

For Payment We may use and disclose health information about you so that the treatment and services you
receive at this office may be billed to and payment may be collected from you, an insurance company or a third
party. For example, we may need to give your health plan information about a service you received here so your
health plan will pay us or reimburse you for the service. We may also tell your health plan about a treatment you are
going to receive to obtain prior approval, or to determine whether your plan will cover the treatment.

For Health Care Operations We may use and disclose health information about you in order to run the office and
make sure that you and our other patients receive quality care. For example, we may use your health information to
evaluate the performance of our staff in caring for you. We may also use health information about all or many of our
patients to help us decide what additional services we should offer, how we can become more efficient, or whether
certain new treatments are effective.

Appointment Reminders We may contact you as a reminder that you have an appointment for treatment or
medical care at the office.

Treatment Alternatives We may tell you about or recommend possible treatment options or alternatives that may
be of interest to you.

Health-Related Products and Services We may tell you about health-related products or services that may be of
interest to you.

Collection of Personal Information

We may use or disclose health information about you without your permission for the following purposes, subject to all applicable legal requirements and limitations:

To Avert a Serious Threat to Health or Safety We may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

Required By Law We will disclose health information about you when required to do so by federal, state or local law. For example, Beverly Drive Dental Care may disclose information for the following purposes:

- For judicial and administrative proceedings pursuant to legal authority;

- To report information related to victim of abuse, neglect or domestic violence; and,

- To assist law enforcement officials in their law enforcement duties.

Assure a Smile encourages you to review the privacy statements of web sites that you choose to visit that may be in association of Assure a Smile, as these websites may not correspond to this Privacy Policy. Assure a Smile is not responsible for the privacy statements or content published on web sites outside of Assureasmile.com.

Research We may use and disclose health information about you for research projects that are subject to a special
approval process. We will ask you for your permission if the researcher will have access to your name, address or
other information that reveals who you are, or will be involved in your care at the office.

Organ and Tissue Donation If you are an organ donor, we may release health information to organizations that
handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to
facilitate such donation and transplantation.

Military, Veterans, National Security and Intelligence If you are or were a member of the armed forces, or part
of the national security or intelligence communities, we may be required by military command or other government
authorities to release health information about you. We may also release information about foreign military
personnel to the appropriate foreign military authority.

Workers' Compensation We may release health information about you in order to comply with the law and
regulations related to workers' compensation or similar programs. These programs provide benefits for work-related
injuries or illness.

Public Health Risks We may disclose health information about you for public health reasons in order to prevent
or control disease, injury or disability; or report births, deaths, suspected abuse or neglect, non-accidental physical
injuries, reactions to medications or problems with products.

Health Oversight Activities We may disclose health information to a health oversight agency for audits,
investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal
agencies to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes If you are involved in a lawsuit or a dispute, we may disclose health information about you
in response to a court or administrative order. Subject to all applicable legal requirements, we may also disclose
health information about you in response to a subpoena.

Law Enforcement We may release health information if asked to do so by a law enforcement official in response to
a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.

Coroners, Medical Examiners and Funeral Directors We may release health information to a coroner or medical
examiner to enable them to carry out their lawful duties. This may be necessary, for example, to identify a deceased
person or determine the cause of death.

Information Not Personally Identifiable We may use or disclose health information about you in a way that does
not personally identify you or reveal who you are.

Family and Friends We may disclose health information about you to your family members or friends if we
obtain your verbal agreement to do so or if we give you an opportunity to object to such a disclosure and you do
not raise an objection. We may also disclose health information to your family or friends if we can infer from the
circumstances, based on our professional judgment that you would not object. For example, we may assume you
agree to our disclosure of your personal health information to your spouse when you bring your spouse with you
into the exam room during treatment or while treatment is discussed. In situations where you are not capable of
giving consent (because you are not present or due to your incapacity or medical emergency), we may, using our
professional judgment, determine that a disclosure to your family member or friend is in your best interest.

In that situation, we will disclose only health information relevant to the person's involvement in your care. For
example, we may inform the person who accompanied you to the emergency room that you suffered a heart attack
and provide updates on your progress and prognosis. We may also use our professional judgment and experience
to make reasonable inferences that it is in your best interest to allow another person to act on your behalf to pick up,
for example, filled prescriptions, medical supplies, or X-rays.

OTHER USES AND DISCLOSURES OF HEALTH INFORMATION

We will not use or disclose your health information for any purpose other than those identified in the previous
sections without your specific, written Authorization. If you give us Authorization to use or disclose health
information about you, you may revoke that Authorization, in writing, at any time. If you revoke your Authorization,
we will no longer use or disclose information about you for the reasons covered by your written Authorization, but
we cannot take back any uses or disclosures already made with your permission.

YOUR RIGHTS REGARDING HEALTH INFORMATION ABOUT YOU

You have the following rights regarding health information we maintain about you:

Right to Inspect and Copy You have the right to inspect and copy your health information, such as medical and
billing records, that we use to make decisions about your care. You must submit a written request to Beverly Drive
Dental Care’s Privacy Officer in order to inspect and/or copy your health information. If you request a copy of the
information, we may charge a fee for the costs of copying, mailing or other associated supplies. We may deny your
request to inspect and/or copy in certain limited circumstances. If you are denied access to your health information,
you may ask that the denial be reviewed. If such a review is required by law, we will select a licensed health care
professional to review your request and our denial. The person conducting the review will not be the person who
denied your request, and we will comply with the outcome of the review.

Right to Amend If you believe health information we have about you is incorrect or incomplete, you may ask us to
amend the information. You have the right to request an amendment as long as the information is kept by this office.
To request an amendment, complete and submit a Dental Record Amendment/Correction Form to Beverly Drive
Dental Care’s Privacy Officer. We may deny your 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 your request if you ask us to amend information that:

a) We did not create, unless the person or entity that created the information is no longer available to make the
amendment.

b) Is not part of the health information that we keep.

c) You would not be permitted to inspect and copy.

d) Is accurate and complete.

Right to an Accounting of Disclosures You have the right to request an "accounting of disclosures." This is a list
of the disclosures we made of medical information about you for purposes other than treatment, payment and health
care operations. To obtain this list, you must submit your request in writing to Beverly Drive Dental Care’s Privacy
Officer. It must state a time period, which may not be longer than six years and may not include dates before April
14, 2012. Your request should indicate in what form you want the list (for example, on paper, electronically). We
may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to
withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions You have the right to request a restriction or limitation on the health information we
use or disclose about you for treatment, payment or health care operations. You also have the right to request a
limit on the health information we disclose about you to someone who is involved in your care or the payment for it,
like a family member or friend. For example, you could ask that we not use or disclose information about a surgery
you had.

We are Not Required to Agree to Your Request If we do agree, we will comply with your request unless the
information is needed to provide you emergency treatment. To request restrictions, you may complete and submit
the Request For Restriction On Use/Disclosure Of Medical Information to Beverly Drive Dental Care’s Privacy
Officer.

Right to Request Confidential Communications You have the right to request that we communicate with you
about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at
work or by mail.

To request confidential communications, you may complete and submit the Request For Restriction On Use/
Disclosure Of Medical Information And/Or Confidential Communication to Beverly Drive Dental Care’s Privacy

Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your
request must specify how or where you wish to be contacted.

CHANGES TO THIS NOTICE


We reserve the right to change this notice, and to make the revised or changed notice effective for medical
information we already have about you as well as any information we receive in the future. We will post a summary
of the current notice in the office with its effective date in the top right hand corner and mail a copy to you.

COMPLAINTS


If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary
of the Department of Health and Human Services. To file a complaint with our office, contact Beverly Drive Dental
Care’s Privacy Officer. You will not be penalized for filing a complaint.

 

TESTIMONIALS

I wish all of my dental experiences were like this! From the front desk to my actual procedure, I felt comfortable and more than pleased with my experience at the office. It was cool to look at the great views during my procedure. It made the time go by so quickly. The staff, the office, the procedure-all superb.

Rodney Franks

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