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NOTICE OF PRIVACY PRACTICES

As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) THIS NOTICE DESCRIBES HOW CERTAIN HEALTH INFORMATION ABOUT YOU, AS A PATIENT OF THIS PRACTICE, MAY BE USED, DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. In conducting our business, the doctors and staff of Dental Visits centers for Cosmetic Dentistry ("DVCCD," "our" or "we") create records regarding you and the treatment and services that we provide to you. We are committed to abide by all applicable laws regarding the protection of your individually identifiable health information ("health information"). This notice is intended to provide information to you about our privacy practices, our legal duties, and your rights concerning your health information.1 This notice is effective as of April 14, 2003 (the "Effective Date") and its scope applies to all records containing your health information that are retained or created by us after the Effective Date. We reserve the right to change our privacy practices and the terms of this notice at any time, and such new privacy practices will be effective for any records that we have created or maintained in the past or that we may create or maintain in the future. Before we make any material changes in our privacy practices, however, we will make our new notice available upon request.

OUR USES AND DISCLOSURES OF HEALTH INFORMATION

For Treatment: We may use your health information to provide you with dental treatment and related services. We may disclose your health information to other dental offices, dentists, physician offices, laboratories, providers, agencies, facilities, pharmacies, transport companies, family members, or other health care providers and their staff involved in providing health related treatment, services or care to you. For example, we may disclose your health information to a pharmacy to write a prescription for you. We may communicate with you about or recommend possible treatment options or alternatives that may be of interest to you. We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters) or informational or promotional materials such as practice newsletters.

For Payment: We may use and disclose your health information (e.g., x-rays, billing statements, etc.) to persons or entities (e.g., insurance companies, family members, third party payers, health plans) so that you (or we as the case may be) can be reimbursed for treatment and services we provide to you.

For Health Care Operations: We may use and disclose your health information for our health care operations. Health care operations include quality assessment and improvement activities, reviewing the competence of health care professionals, evaluating practitioner and provider performance, conducting educational or training programs, accreditation, certification, licensing or credentialing activities or to detect or prevent health care fraud and abuse, contractual obligations, patients?claims, grievances or lawsuits, health care contracting, legal, tax, or business planning and development, business management and administration, promotional programs, the sale of all or part of DVCCD to another entity, underwriting, claims management and other insurance activities. We may disclose your health information to another health care provider or organization to support some of their health care operations.

Relatives, Caregivers and Personal Representatives: We may disclose your health information to a family member, friend, personal representative, or other person you identify that is involved in your dental or health care or with payment for your dental or health care. Unless you have otherwise provided us the authorization to do so, before we disclose your health information to such people, we will provide you with an opportunity to object to our use or disclosure. If you are not present, or in the even of your incapacity or an emergency, we will disclose your medical information based on our professional judgment of whether the disclosure would be in your best interest. We may 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. We may use or disclose information about you to notify or assist in notifying a person involved in your care, of your location and general condition.

Health Related Benefits and Services: We may contact you about benefits or services that we provide.

Disaster Relief Efforts: We may use or disclose your health information to a public or private entity authorized by law or by its charter to assist in disaster relief efforts.

News Gathering Activities: We may contact you or one of your family members to discuss whether or not you want to participate in a media or news story (e.g., a news reporter working on a story about dental health may ask whether any patients undergoing some sort of specific dental treatment may be willing to interviewed).

Public Benefit: We may use or disclose your medical information as authorized by law for the following purposes deemed to be in the public interest or benefit, including without limitation, for public health activities, including disease and vital statistic reporting, child abuse reporting, FDA oversight, and to employers regarding work-related illness or injury; to report adult abuse, neglect, or domestic violence; to health oversight agencies; to coroners, medical examiners, and funeral directors; to an organ procurement organizations; to avert a serious threat to health or safety; in connection with certain research activities; and to the military and to federal officials for lawful intelligence, counterintelligence, and national security activities.

Authorized or Required By Law: We will disclose health information when authorized or required to do so by applicable law, including without limitation, in response to court and administrative orders and other lawful processes; to law enforcement officials pursuant to subpoenas and other lawful processes, concerning crime victims, suspicious deaths, crimes on our premises, reporting crimes in emergencies, and for purposes of identifying or locating a suspect or other person; to correctional institutions regarding inmates; and as authorized by state workers?compensation laws.

Lawsuits and Similar Proceedings: In connection with lawsuits or other legal proceedings, we may disclose health information about you in response to a court or administrative order, or in response to a subpoena, discovery request, warrant, summons, or other lawful process. We may disclose health information to courts, attorneys, and court employees in the course of litigation, arbitration, or other judicial or administrative proceedings.

Law Enforcement: If asked to do so by law enforcement, and as authorized or required by law, we may release medical information: to identify or locate a suspect, fugitive, material witness, or missing person; about a suspected victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; about a death suspected to be the result of criminal conduct; about criminal conduct at DVCCD; and in case of a medical emergency, to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors: In most circumstances, we may disclose medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine cause of death. We may also disclose medical information about patients of DVCCD to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities: As authorized or required by law, we may disclose medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities.

Other Uses of Health Information: Not every specific use or disclosure of your health information is listed in this notice. Unless you provide us (or have already provided us) with separate written authorization to use or otherwise disclose certain personal or health information for certain purposes, all of the ways we are permitted to use and disclose health information will fall within one of the following categories.

PATIENT RIGHTS

Your health information that we have created and maintain is the property of DVCD. You have the following rights, however, regarding your health information that we maintain.

Right to Inspect and Copy: You have the right to look at or get copies of your health information, with certain exceptions. You may make reasonable requests that we provide copies in a format other than photocopies. We will use the format you request unless it is unduly burdensome to do so. You must make a request in writing to obtain access to your health information by sending a letter to the Privacy Officer identified at the bottom of this notice. If you request copies, we will charge you a fee for these services that may include labor, duplication costs, and postage. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we may ?but are not required to ?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 more information about fees.

Right to Amend: You have the right to request that we amend your health information if you believe that the health information that we have about you is incorrect or incomplete. Your request must be in writing to the Privacy Officer identified at the bottom of this notice, and it must explain reasons that support your request to amend your health information. We may deny your request under certain circumstances (e.g., it is not in writing, does not have support for the request, asks that we amend information that is accurate or complete, was not created by DVCCD, etc.).

Right to Disclosure Accounting: You have the right to request a list of certain disclosures we have made of your health information. To request this accounting of disclosures, you must submit your request in writing to the Privacy Officer identified at the bottom of this notice. Your request must state a time period longer than the previous six years and may not include dates before April 14, 2003. That list will not include disclosures for treatment, payment, health care operations, as otherwise authorized by you, and for certain other activities. 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. Contact us using the information listed at the end of this notice for more information about fees.

Right to Request Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information for treatment, payment or healthcare operations. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). In your request, you must tell us: (1) what information you want us to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply. We are not required to agree to your request. If we do agree, our agreement must be in writing signed by a person authorized to make such agreement on our behalf and we will endeavor to comply unless the information is needed to provide emergency treatment.

Right to Alternative Communication: You have the right to request that we communicate with you about your health information in a certain way or at a certain location. You must make your request in writing to the Privacy Officer identified at the bottom of this notice. You must specify in your request the alternative means or location, and provide satisfactory explanation how you will handle alternative payment under the alternative means or location you request. We will endeavor to comply with all reasonable requests.

Right to Copies of This Notice: You may request a paper copy of our notice and we will endeavor to keep a current copy posted on our website located at www.dentalvisits.com. 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.

Right to File A Complaint: You may contact the Privacy Officer listed at the bottom of this notice if you believe that we have violated your privacy rights, we made a decision about access to your health information incorrectly, our response to a request you made to amend or restrict the use or disclosure of your health information was incorrect, or we should communicate with you by alternative means or at alternative locations. 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 will not penalize you on the basis of filing a complaint.

CONTACT INFORMATION

If you want more information about our privacy practices or have questions or concerns, please contact us using the information listed below.

Dental Visits for Cosmetic Dentistry
Attn: Neville S Coward, Privacy Officer
140 East 56th Street, Suite 1A
New York, New York 10022

Phone: 212-697-0939
Fax: 212-471-0266

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES NOTICE

Include This Acknowledgement In the Patient’s Records

Please sign and date below to indicate that you have received a copy of our Privacy Policy notice. Your signature simply acknowledges that you received a copy of this notice.

Print Name:
Signature:
Date:

Patient’s Authorized Representative

If Patient is Under 18 Years of Age or you are Consenting To The Care Of Another

If a personal representative signs this authorization on behalf of the individual, the representative states that he/she has the legal authority to sign this acknowledgement on behalf of the following patient:
Patient’s Printed Name:
Personal Representative’s Printed Name:
Relationship to Individual:
Personal Representative’s Signature:
Date:

Good Faith Effort to Obtain Acknowledgement of Receipt

If Patient or Patient’s Representative Refuses To Acknowledge Receipt

Describe the reason why the individual would not sign this form:

Let's face it, nobody likes to be surprised when it comes to costs. That's why we have established a policy of informing you of the costs associated with the treatment prior to starting the treatment.

Here's how it works. Once we have completed your initial exam, cleaning, necessary x-rays, diagnostics, smile analysis and consultation, which is presently an investment of $328 for most patients, we will review our recommended treatment plan and its projected cost with you. That way, you can make specific financial arrangements before we begin. To make getting a beautiful smile as easy as possible, we offer several convenient payment methods from which to choose.

These plans are set out below. Our treatment coordinators are available to discuss financial arrangements and select the method of payment that best meets your needs.

Time & Method of Payment

Unless specific prior arrangements have been made, full payment is due at the time of service or for large cosmetic cases, prior to the commencement of the case. We will accept payment in cash, checks, Visa, Mastercard, American Express or Discover Card.

Extended Payment Plan

For larger treatment plans up to and exceeding $25,000, we offer a long-term financing option subject to prior credit approval. Here are some features: No down payment. Usually, 90 days same as cash. You can select a monthly payment that fits within your budget. Your payments will never change with fixed rates ranging from 9.99% to 12.99%. No prepayment penalty. The application process can be as fast as 15 minutes and is confidential. There are no application fees. Our staff will be happy to provide additional information and answer your questions. Just think, within 15 minutes you can be approved and ready to get your beautiful smile right away!

Dental Insurance

Many of our clients are covered by some sort of dental insurance. These policies can vary widely in the amount and scope of coverage. Although most dental insurance plans do not cover procedures deemed purely cosmetic, in some cases, certain cosmetic procedures are also preventive and functional. These procedures may or not be covered by your insurance plan. To make the process as simple as possible for all of us, we have set established the following policy. Clients are expected to take full responsibility for the payment of our fee at the time treatment is rendered. We will assist clients in expediting reimbursement of insurance benefits by providing the detailed statements for filing with insurance companies. If you have any questions concerning insurance issues, please contact our front office, and one of our concierges will be happy to help you. We are pleased to offer Dental Fee Plan (DFP) Financing to our patients. DFP is a convenient, no initial payment, low monthly payment plan for dental treatments of $1,000 to $25,000. Offering DFP allows us to make the smile you've always wanted affordable. This website is intended to be a public service resource of general information that Dental Visits Centers for Cosmetic Dentistry ("DVCCD") believes, but does not warrant or guarantee, to be correct, complete, and up-to-date. This website is not intended to constitute the practice of dentistry, nor is it intended to constitute an advertisement to anyone outside the State of New York. Dental Visits for Cosmetic Dentistry is registered with the State of New York as a service mark and is a trade name of Judy J Johnson, D.D.S. Other marks which appear on this Web site may be marks owned by third parties that are not affiliated with, nor endorse, DVCCD and DVCCD hereby disclaims such affiliation, ownership or endorsement.

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