Little Sprouts Dental, LLC

Joint Notice of Privacy Practices

Adopted April 1, 2013

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY.

Most patients of Little Sprouts Dental, LLC are children; when we refer to “you” or “your” in this Notice, we refer to the patient. When we refer to disclosures of information to“you,” we mean disclosures to the patient, the patient’s parent, guardian or other person legally authorized to receive information about the patient.

Who follows this Notice:

This Notice applies to all patient health information maintained by Little Sprouts Dental, LLC for services provided at W62N563 Washington Avenue, Cedarburg, Wisconsin. If you have any questions after reading this notice, please contact Little Sprouts Dental, LLC.

Each time you visit Little Sprouts Dental, LLC, a record of your visit is made. Typically, this record contains symptoms, examination and test results, diagnoses, treatment and billing-related information. This Notice applies to all of the records of your care generated by Little Sprouts Dental, LLC whether made by employees, agents or your dentist.

Our Pledge to Protect Your Health Information: We are required by law to maintain the privacy of your health information and provide you with this description of our privacy practices. We will abide by the terms of this Notice.

HOW WE MAY USE AND SHARE YOUR HEALTH INFORMATION WITH OTHERS:

➢ For Treatment: We will use health information about you to provide you with dental treatment or services. We will disclose health information about you to dentists, medical doctors, assistants, dental hygienists, technicians, or to students in dental training programs who are involved in taking care of you, in order to coordinate the different things you need, such as treatment, prescriptions, lab work, and x-rays. We also may disclose health information about you to people outside Little Sprouts Dental, LLC who provide your dental care outside of our organization, such as dental specialists, referring dentists, dental laboratories or a dentist to whom you are transferring your care.

➢ For Payment: Little Sprouts Dental, LLC will use and disclose your health information to send bills and collect payment from you, your insurance company, or other payors, such as Medicaid, for the care, treatment and other related services you receive from our organization. We also may provide your name, address, health care and insurance information to other care providers (for example, your physician) related to your care at our organization. We also may tell your health insurer about a treatment your dentist recommended in order 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 for Little Sprouts Dental, LLC’s business operations. These uses and disclosures are necessary to run the organization and make sure that all of our patients receive quality care and cost-effective services.

For example, we may use health information to review the quality of our treatment and services, to develop new programs as part of promoting health and to evaluate our performance in caring for you.

➢ Appointments: Little Sprouts Dental, LLC may contact you for appointments. Messages left for you will not contain specific health information.

➢ Required or Permitted By Law: Little Sprouts Dental, LLC is required by law to disclose your health information in certain circumstances to:

Control or prevent a communicable disease, injury or disability, and for public health oversight activities or interventions.

The Food and Drug Administration (FDA) to report adverse events or product defects, to track products, to enable product recalls, or to conduct post-market surveillance as required by law.

A state or federal government agency to facilitate their functions.

Report suspected child or elder abuse to law enforcement agencies responsible to investigate or prosecute abuse.

Respond to a valid court order.

The Department of Health and Family Services (DHFS), a protection or advocacy agency or law enforcement authorities investigating abuse, neglect, physical injury, death, violent crimes involving suspicious wounds, burns, gunshot wounds or death.

Your court-appointed guardian or an agent appointed by you under a health care power of attorney.

Prison officials if you are in custody.

Worker’s Compensation officials if your injury or illness is work-related.

➢ Research: Under certain circumstances, Little Sprouts Dental, LLC may use and disclose your health information for research purposes. For example, a research project might compare the health and recovery of all patients who received one treatment to those who received another for the same condition. For this type of project, Little Sprouts Dental, LLC may waive the need for consent and any published results would not include information that identifies you. In other circumstances, you will be asked to give consent to participate in a research project. You may choose not to participate in research. Your care and treatment will not be affected by your decision.

When sharing information with others outside Little Sprouts Dental, LLC, we share only what is reasonably necessary unless we are sharing information to help treat you, in response to your written permission, or as the law requires. In these cases, we share all the information that you, your health care provider or the law has requested.

YOUR HEALTH INFORMATION RIGHTS

➢ Right to Request Restrictions: You have the right to request certain restrictions of Little Sprouts Dental, LLC’s use or disclosure of health information for treatment, payment or health care operations. You also have the right to request a restriction on our disclosure of your health information to someone who is involved in your care or the payment for your care.

Little Sprouts Dental, LLC is not required to agree to your request if it interferes with patient care, treatment, office/clinic operations and/or payment of your bill.

If Little Sprouts Dental, LLC does agree to the restriction, it will comply with your request unless the information is needed to provide you with emergency treatment. A request for restriction must be made in writing.

➢ Right to Inspect and Copy: You have the right to inspect and receive a copy of your health records. A request to inspect your records, receive copies of your health information or billing information may be made in writing at any time.

➢ Right to Amend: If you feel that health information we have about you is incorrect or incomplete, you may ask us to amend the information for as long as the information is maintained by Little Sprouts Dental, LLC. Requests for amending your health information must be made in writing. The organization will respond to your request within 60 days after you submit the written amendment request.

➢ Right to an Accounting of Disclosures: You have the right to request an “accounting of disclosures.” This is a list of those people with whom Little Sprouts Dental, LLC may have shared your health information, with exception of information shared for purposes of treatment, payment or health care operations or when you have provided us with an authorization to do so. To request an accounting of disclosures, you must submit your request in writing. We will provide the list at no cost once during each 12-month period. For any additional requests, we may charge you a fee for the cost of providing the list. We will notify you of the fee and you may choose to withdraw or modify your request at that time before any costs are incurred.

➢ Right to Request Confidential Communications: You have the right to request that we communicate with you about your health information in a certain way or at a certain location. For example, you can ask that we contact you only at work or by mail. We will accommodate all reasonable requests.

➢ Right to Revoke Authorization: Uses and disclosures of health information not covered by this Notice or the laws that apply to Little Sprouts Dental, LLC will be made only with your authorization. If you authorize the organization to use or disclose your health information, you may revoke that authorization in writing at any time. We are unable to take back any disclosures we have already made with your permission.

➢ Right to Complain: If you believe your privacy rights have been violated, you may file a complaint with Little Sprouts Dental, LLC or with the Secretary of the Department of Health and Human Services. To file a complaint with Little Sprouts Dental, LLC, contact our office. All complaints must be made in writing. We will assist you in filing your complaint and the necessary paperwork. Filing a complaint will not affect your care and treatment.

Important Note: We reserve the right to revise or change this Notice.
We will provide you with a copy of the Notice in effect.

Effective Date: April 1, 2013