NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW YOUR PERSONAL AND MEDICAL INFORMATION MAY BE COLLECTED, USED, AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THROUGH THE USE OF OUR WEBSITE, YOU ARE CONSENTING TO THE DATA COLLECTION, USE, AND DISCLOSURE PROCEDURES EXPRESSED IN THIS NOTICE.

Effective date: December 5, 2024

Summary

This is a summary of how we may use and disclose your protected health information and your rights and choices when it comes to your information. We will explain these in more detail on the following pages.

Your Rights

You have the right to:

• Get a copy of your paper or electronic protected health information.
• Correct your protected health information.
• Ask us to limit the information we share, in some cases.
• Get a list of those with whom we’ve shared your information.
• Request confidential communication.
• Get a copy of this privacy notice.
• Choose someone to act for you.
• File a complaint if you believe we have violated your privacy rights.

Your Choices

You have some choices about how we use and share information as we:

• Communicate with you.
• Tell family and friends about your condition.
• Provide disaster relief.
• Market our services

Our Uses and Disclosures

We may use and disclose your information as we:

• Treat you and coordinate your care.
• Bill for services.
• Run our organization.
• Comply with the law.
• Helping with public health and safety issues.
• Respond to lawsuits and legal actions.
• Do research.
• Work with a medical examiner or funeral director.
• Address workers’ compensation, law enforcement, and other government requests.

Purpose

US Oral Surgery Management, LLC and its subsidiaries and affiliates that are directly or indirectly, through one or more intermediaries, under common ownership or control therewith and subject to HIPAA (hereinafter defined) (collectively, “Practice” or “We”) respect your privacy. We are also legally required to maintain the privacy of your protected health information (“PHI”) under the Health Insurance Portability and Accountability Act (“HIPAA”) and other federal and state laws. We follow state privacy laws, including when they are stricter or more protective of your PHI than federal law.

As part of our commitment and legal compliance, we are providing you with this Notice of Privacy Practices (“Notice”). This Notice describes:

• Our legal duties and privacy practices regarding your PHI, including our duty to notify you following a data breach of your unsecured PHI.
• Our permitted uses and disclosures of your PHI.
• Your rights regarding your PHI.

Contact

If you have any questions about this Notice, please contact our Director of Compliance at compliance@usosm.com.

PHI Defined

Your PHI:

• Is health information about you:
  • which someone may use to identify you; and
  • which we keep or transmit in electronic, oral, or written form.
• Includes information such as your:
  • name;
  • contact information;
  • past, present, or future physical or mental health or medical conditions;
  • payment for health care products or services; or
  • prescriptions.

Scope

We create a record of the care and health services you receive, to provide your care, and to comply with certain legal requirements. This Notice applies to all the PHI that we generate and that you provide us.

We and our employees and other workforce members follow the duties and privacy practices that this Notice describes and any changes once they take effect.

Changes to this Notice

We can change the terms of this Notice, and the changes will apply to all information we have about you. The new notice will be available on request, in our office, and on our website.

Data Breach Notification

We will promptly notify you within the legally required time frame if a data breach occurs that may have compromised the privacy or security of your PHI. Most of the time, we will notify you in writing, by first- class mail, or we may email you if you have provided us with your current email address and you have previously agreed to receive notices electronically. In some circumstances, our business may provide the notification. In limited circumstances when we have insufficient or out-of-date contact information, we may provide notice in a legally acceptable alternative form.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

You have the right to:

• Get a copy of your PHI. You can ask to see or obtain an electronic or paper copy of the PHI that we maintain about you (right to request access). Alternatively, you may request a summary of your PHI or an explanation of your PHI. You can ask us how to do this. Some clarifications about your access rights:
  • we may require you to make access requests in writing;
  • we may charge a reasonable, cost-based fee for the costs of copying, mailing, or other supplies associated with your request. This fee complies with applicable state and federal laws;
  • you may request that we provide a copy of your PHI to a family member, another person, or a designated entity. We require that you submit these requests in writing with your signature, and clearly identify the designated person and where to send the PHI;
  • you may request that we direct a copy of your PHI to a third party of your choice on a standing, regular basis. We require that you submit these requests in writing;
  • if you request a copy of your PHI, we will generally decide to provide or deny access within 30 days (unless your state’s law imposes a shorter time frame, in which case we will act in accordance with such shorter time frame), however, if we cannot act within 30 days (or, if applicable, such shorter time period required by your state’s laws), we will give you a reason for the delay in writing and when you can expect us to act on your request; and
  • we may deny your request for access in certain limited circumstances, however, if we deny your access request, we will provide a written denial with the basis for our decision and explain your rights to appeal or file a complaint.
• Ask us to correct your medical record. You may ask us to correct or amend PHI that we maintain about you that you think is incorrect or inaccurate. For these requests:
  • you must submit requests in writing, specify the inaccurate or incorrect PHI, and provide a reason that supports your request;
  • we will generally decide to grant or deny your request within 60 days. If we cannot act within 60 days, we will give you a reason for the delay in writing and include when you can expect us to complete our decision, which will be no longer than an additional 30 days, subject to one extension;
  • we may deny your request for an amendment if you ask us to amend PHI that is not part of our record, that we did not create, that is not part of a designated record set, or that is accurate and complete;
  • if we deny your request, we will tell you why in writing. You will have the right to submit a written statement disagreeing with the denial and, if you opt not to submit this statement, you may request that we provide your original request for amendment and the denial with any future disclosures of PHI subject to the amendment. However, we may prepare a written rebuttal to any individual’s statement of disagreement; and
  • we will append the material created or submitted in accordance with this paragraph to your designated record.
• Ask us to limit what we use or share. You have the right to ask us to limit what we use or share about your PHI (right to request restrictions). You can contact us and request us not to use or share certain PHI for treatment, payment, or operations or with certain persons involved in your care. We may require that you submit this request in writing. For these requests:
  • we are not required to agree;
  • we may say “no” if it would affect your care; but
  • we will agree not to disclose information to a health plan for purposes of payment or health care operations if the requested restriction concerns a health care item or service for which you or another person, other than the health plan, paid in full out-of-pocket, unless it is otherwise required by law.
• Get a list of those with whom we’ve shared your PHI. You have the right to request an accounting of certain PHI disclosures that we have made. For these requests:
  • we will respond no later than 60 days after receiving the request. We may ask for an additional 30 days during this 60-day period, but if we do, we will only do it once, provide a written statement of why, and indicate the date by which we intend to send the response;
  • we will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures, such as any you asked us to make; and
  • we will provide one accounting a year for free, but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
• Choose someone to act for you. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your PHI. We will confirm the person has this authority and can act for you before we take any action.
• Request confidential communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or at a specific address. For these requests:
  • we will not ask for the reason;
  • you must specify how or where you wish to be contacted; and
  • we will accommodate reasonable requests.
• Make a complaint. You have the right to complain if you feel we have violated your rights. We will not retaliate against you for filing a complaint. You may either file a complaint:
  • directly with us by contacting our Director of Compliance at compliance@usosm.com. All complaints must be submitted in writing; or
  • with the Office for Civil Rights at the US Department of Health and Human Services. Their website is www.hhs.gov/ocr/privacy/hipaa/complaints/.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, please contact us and we will make reasonable efforts to follow your instructions.

In these cases, you have both the right and choice to tell us whether to:

• Share information, such as your PHI, general condition, or location, with your family, close friends, or others involved in your care.
• Share information in a disaster relief situation, such as to a relief organization to assist with locating or notifying your family, close friends, or others involved in your care.

If you are not able to tell us your preference, for example if you are unconscious, we may share your information if we believe it is in your best interest, according to our best judgment. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

Wisconsin law generally requires patient consent to share health information with family members or friends, except as required or authorized by law.

In these cases, we will not share your information unless you give us your written permission:

• Marketing purposes.
• Certain research activities.
• Other uses and disclosures not described in this Notice.

You may revoke your authorization at any time, but it will not affect information that we already used and disclosed.

Uses and Disclosures of Your PHI

The law permits or requires us to use or disclose your PHI for various reasons, which we explain in this Notice. We have included some examples, but we have not listed every permissible use or disclosure. When using or disclosing PHI or requesting your PHI from another source, we will make reasonable efforts to limit our use, disclosure, or request about your PHI to the minimum we need to accomplish our intended purpose. PHI that the law permits or requires us to disclose may be further shared by recipients and is no longer protected by law or the safeguards and restrictions in place when it is in our possession.

Uses and Disclosures for Treatment, Payment, or Health Care Operations

• Treatment. We may use or disclose your PHI and share it with other professionals who are treating you, including doctors, nurses, technicians, dentists, or personnel involved in your care. For example, we might disclose information about your oral health condition to dentists who are also treating you.
• Billing and payment. We may use and disclose your PHI to bill and get payment from health plans or others. For example, we share your PHI with your health insurance plan so it will pay for the services you receive.
• Running our organization. We may use and disclose your PHI to run our practice, improve your care, and contact you when necessary. For example, we may use your PHI to manage the services and treatment you receive or to monitor the quality of our health care services.

Other Uses and Disclosures

We may share your information in other ways, usually for public health or research purposes or to contribute to  the  public  good.  For  more  information  on  permitted  uses  and  disclosures,  see

www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. For example, these other uses and disclosures may involve:

• Our business associates. We may use and disclose your PHI to outside persons or entities that perform services on our behalf, such as auditing, legal, or transcription (“Business Associates”). The law requires our business associates and their subcontractors to protect your PHI in the same way we do. We also contractually require these parties to use and disclose your PHI only as permitted and to appropriately safeguard your PHI.
• Electronic Data Exchanges. Consistent with applicable law, we may send you text messages, emails or other electronic communications for treatment, payment, healthcare operations and other permitted purposes. Our Practice may participate in one or more Health Information Exchanges (“HIEs”) and may electronically share your PHI for treatment, payment, healthcare operations and other permitted purposes with other participants in the HIE. HIEs allow your healthcare providers to efficiently access and use your PHI as necessary for treatment and other lawful purposes.
• Complying with the law. For example, we will share your PHI if the Department of Health and Human Services requires it when investigating our compliance with privacy laws.
• Helping with public health and safety issues. For example, we may share your PHI to:
  • report injuries, births, and deaths;
  • prevent disease;
  • report adverse reactions to medications or medical device product defects;
  • report suspected child neglect or abuse, or domestic violence; or
  • avert a serious threat to public health or safety.
• Responding to legal actions. For example, we may share your PHI to respond to:
  • a court or administrative order or subpoena;
  • discovery request; or
  • another lawful process.

However, in many situations we are prohibited from sharing, and will not share, your PHI for investigations or legal actions concerning reproductive health care access and services where that care is lawful as provided. For example, the law prohibits us from using or disclosing your reproductive health care-related PHI in many instances to:

• respond to investigation requests, court orders, or subpoenas seeking information about or imposing liability on any person for seeking, obtaining, providing, or facilitating lawfully provided reproductive health care; or
• identify any person that is subject to a criminal, civil, or administrative investigation or legal action, including any in law enforcement investigations, criminal prosecutions, family law proceedings, or state licensure proceedings, for seeking, obtaining, providing, or facilitating lawfully provided reproductive health care.

Some examples of seeking, obtaining, providing, or facilitating reproductive health care include: using reproductive health care; performing, furnishing, or paying for reproductive health care; providing information about reproductive health care; arranging, insuring, administering, providing coverage for, approving, or counseling about reproductive health care; or attempting any of these activities.

For more information on these prohibited uses and disclosures and when the prohibition applies, see https://www.hhs.gov/hipaa/for-professionals/special-topics/reproductive-health/final-rule- fact-sheet/index.html.

• Research. For example, we may share your PHI for some types of health research that do not require your authorization, such as if an institutional review board (“IRB”) has waived the written authorization requirement.
• Working with medical examiners or funeral directors. For example, we may share PHI with coroners, medical examiners, or funeral directors when an individual dies.
• Addressing workers’ compensation, law enforcement, or other government requests. For example, we may use and disclose your PHI for:
  • workers’ compensation claims;
  • health oversight activities by federal or state agencies;
  • law enforcement purposes or with a law enforcement official; or
  • specialized government functions, such as military and veterans’ activities, national security and intelligence, presidential protective services, or medical suitability.

Acceptance of Terms

By using our website, you are hereby accepting the terms and conditions stipulated within this Notice. If you are not in agreement with our terms and conditions, then you should refrain from further use of our sites. In addition, your continued use of our website following proper notification or the posting of any updates or changes to our terms and conditions shall mean that you agree and accept such changes.

How to Contact Us:

If you have any questions or concerns regarding this Notice, please feel free to contact us at the following email, telephone number, or mailing address:

DrDental PLLC 

400 Maplelawn Dr., #102, Plano, TX 75075

Attention: Director of Compliance Phone Number: (866) 869-8265 Email: compliance@usosm.com