Notice of Privacy Practices

FAMILY MEDICAL DENTAL CENTER
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH IINFORMATION 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 laws to maintain the privacy of
your health information. We are also required to give 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 April 14, 2003, 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 NFORMATION

We use and disclose health information about you for treatment, payment, and
healthcare operations. For example:
TREATMENT: We may use or disclose your health information to a physician or other
healthcare provider providing treatment to you.
PAYMENT: We may use and disclose your health information to obtain payment for
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,
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 additional 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 i f you agree that we
may do so.

PERSONS INVOLVED IN CARE: We may use or disclose your 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. n 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.

MARKETING HEALTH-RELATED SERVICES: We will not use your health information for
marketing communications without your 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 institutions or law
enforcement officials having lawful custody of protected health information of inmates or
patients 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.)

PATIENT RIGHTS
ACCESS: You have the right to look at or get copies of your health information, with
limited exceptions. 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 reserve the right to
charge you a reasonable cost for each page, and for staff time to locate and copy
your health information, and postage if you want copies mailed to you. If you
request an alternate 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 us using the information
listed at the end of this Notice for a full explanation of our fee structure.)

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 April 14, 2003. 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 an 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 (email),
you are entitled to receive this Notice in written form.

QUESTIONS AND COMPLAINTS
If you want 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, or in response to a request
you made to amend or restrict the use or disclosure of your health information, or to
have us communicate with you by alternative means or at alternative locations, 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 health information. We will not retaliate
in any way if you choose to file a complaint with us or with the U.S. Department of
Health and Human Services.

Contact Officer: Roberta Stanley
Telephone: (907) 333-1211 Fax: (907) 333-8600
E-Mail: frontdesk@familymedicaldental.com
Address: Family Medical Dental Center
PO Box 210549
Anchorage, AK 99521-0549

FAMILY MEDICAL DENTAL CENTER
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION


Section A: Patient Giving Consent

Name:
Address:
Telephone: Email:
Patient chart no. Social Security Number:

Section B: To the Patient PLEASE READ THE FOLLOWING STATEMENS CAREFULLY

Purpose of consent: By signing this form you will consent to our use and disclosure of
your protected health information to carry out treatment, payment activities, and
healthcare operations.

Notice of Private Practices: You have the right to read our Notice of Privacy Practices
before you decide whether to sight this Consent. Our Notice provides a description of our
treatment, payment activities, and healthcare operations, of the uses and disclosures we
may make of your protected health information, and other important matters about your
protected health information. A copy of our Notice accompanies this Consent. We
encourage you to read it carefully and completely before signing this Consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy
Practices. If we change our privacy practices, we will issue a revised Notice of Privacy
practice, which will contain the changes. Those changes may apply to any of your
protected health information that we maintain.
You may obtain a copy of you Notice of Privacy Practices, including any revisions of our
Notice, at any time by contacting:

Contact Person: Roberta Stanley
Address: PO Box 210549, Anchorage, AK 99521-0549
Telephone: 907-333-1211
Email: frontdesk@familymedicaldental.com

Right to Revoke: You will have the right to revoke this Consent at any time by giving written
notice of your revocation submitted to the Contact person Listed above. Please understand that
revocation of this consent will not affect any action we took in reliance on this Consent before we
received your revocation, and that we may decline to treat your or to continue treating you if you
revoke this Consent.

Signature
I, ____________________________________, have had full opportunity to read and consider
the contents of this Consent form and your Notice of Privacy Practices. I understand that, by
signing this Consent form, I am giving my consent to your use and disclosure of my protected
health information to carry out treatment, payment activities and healthcare operations.
Signature: _______________________________________Date:__________________

If this Consent is signed by a personal representative on behalf of the patient, complete the
following:
Personal Representative: _____________________________________________
Relationship to patient: _____________________________________________

You are entitled to a copy of this Consent after you sign it.

FAMILY MEDICAL DENTAL CENTER
ACKNOWLEDGEMENT OF RECEIPT FOR NOTICE OF PRIVACY PRACTICES

* You may refuse to sign this Acknowledgement *

I, _______________________________, have received a copy of this offices’ Notice of
Privacy Practices.
Please Print Name:
Signature:
Date:

*FOR OFFICE USE ONLY
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy
Practices, but acknowledgement could not be obtained because:
Individual refused to sign.
Communications barrier prohibited obtaining the acknowledgement.
An emergency situation prevented us from obtaining acknowledgement.
Other: (please specify)