Notice of Privacy Practices

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.

Oral Facial Surgery Institute is required by law to provide you with this notice that explains our privacy practices with regard to your medical information and how we may use and disclose your protected health information for treatment, payment, and for health care operations, as well as for other purpose that are permitted or required by law. You have certain rights regarding the privacy of your protected health information and we also describe them in this notice.

Ways in Which We May Use and Disclose Your Protected Health Information:

The following paragraphs describe different ways Oral Facial Surgery Institute uses and discloses your protected health information. We have provided an example for each category, but these examples are not meant to be exhaustive. We assure you that all of the ways we are permitted to use and disclose your health information will fall within one of these categories.

Treatment. Oral Facial Surgery Institute may use and disclose your protected health information to provide, coordinate, and/or manage your health care and any related services. Oral Facial Surgery Institute will also disclose your health information to other physicians who may be treating you. Additionally, we may from time to time disclose your health information to another physician whom we have requested be involved in your care. For example – we would disclose your health information to a specialist to whom we have referred you for diagnosis to help in your treatment.

Payment. Oral Facial Surgery Institute may use and disclose your protected health information to obtain payment for the health care services we provide to you. For example – we may include information, with a bill to a third-party payer, which identifies you, your diagnosis, procedures performed, and supplies used in rendering the service.

Health Care Operations. Oral Facial Surgery Institute may use and disclose your protected health information to support the business activities of our practice. For example – we may use medical information about you to review and evaluate our treatment and services or to evaluate our staff’s performance while caring for you. In addition, we may disclose your health information to third party business associates who perform billing, consulting, or transcription services for our practice.

Other Ways We May Use and Disclose Your Protected Health Information:

Appointment Reminders. Oral Facial Surgery Institute may use and disclose your protected health information to contact you as a reminder about scheduled appointments or treatment.

Treatment Alternatives. Oral Facial Surgery Institute may use and disclose your protected health information to tell you about or to recommend possible alternative treatments or options that may be of interest to you.

Others Involved in Your Care. Oral Facial Surgery Institute may use and disclose your protected health information to a family member, your personal representative or another person responsible for your care, a relative, a close friend, or any other person you identify that is involved in your medical care or payment for care.

Research. Oral Facial Surgery Institute may use and disclose your protected health information to researchers provided the research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.

As Required by Law. Oral Facial Surgery Institute will use and disclose your protected health information when required to by federal, state, or local law. You will be notified of any such disclosures.

To Avert a Serious Threat to Public Health or Safety. Oral Facial Surgery Institute will use and disclose your protected health information to a public health authority that is permitted to collect or receive information for the purpose of controlling disease, injury, or disability. If directed by that health authority, we will also disclose your health information to a foreign government agency that is collaborating with the public health authority.

Workers Compensation. Oral Facial Surgery Institute may use and disclose your protected health information for workers compensation or similar programs that provide benefits for work-related injuries or illness.

Inmates. Oral Facial Surgery Institute will use and disclose your protected health information to a correctional institution or law enforcement official if you are an inmate of that correctional institution or under the custody of the law enforcement official. This information would be necessary for the institution to provide you with health care; to protect the health and safety of others; or for the safety and security of the correctional institution.

Although your health record is the physical property of the health care practitioner or the facility that compiled it, the information belongs to you. You have the right to:

A Paper Copy of This Notice. You have the right to receive a paper copy of this notice upon request. You may obtain a copy by asking our receptionist at your next visit or by calling and asking us to mail you a copy.

Inspect and Copy. You have the right to inspect and copy the protected health information that Oral Facial Surgery Institute maintains about you in our designated record set for as long as we maintain that information. This designated record set includes your medical and billing records, as well as any other records Oral Facial Surgery Institute uses for making decisions about you. Any psychotherapy notes that may have been included in records we received about you are not available for your inspection or copying by law. Oral Facial Surgery Institute may charge you a fee for the costs of copying, mailing, or other supplies used in fulfilling your request.

If you wish to inspect or copy your medical information, you must submit your request in writing to Oral Facial Surgery Institute, Attn: Practice Manager, 621 S. New Ballas Road, Suite 16A, St. Louis, Missouri 63141. You may mail in your request or bring it to our office. Oral Facial Surgery Institute will have 30 days to respond to your request for information that we maintain at our practice site. If the information requested is stored off-site, we are allowed up to 60 days to respond but must inform you of this delay.

Request Amendment. You have the right to request that we amend you medical information if you feel that it is incomplete or inaccurate. You must make this request in writing to our Practice Manager stating exactly what information is incomplete or inaccurate and your reasoning that supports your request.

Oral Facial Surgery Institute is permitted to deny your request if it is not in writing or does not include a reason to support the request. We may also deny your request if:

• the information was not created by us, or the person who created it is no longer available to make the amendment;

• the information is not part of the record which you are permitted to inspect and copy;

• the information is not part of the designated record set kept by this practice; or

• if it is the opinion of the health care provider that the information is accurate and complete.

Request Restrictions. You have the right to request a restriction or limitation on how Oral Facial Surgery Institute uses or discloses your medical information for treatment, payment, or health care operations. For example – you could request that we not disclose information about a prior treatment to a family member or friend who may be involved in your care or payment for care. Your request must be made in writing to our Practice Manager.

Oral Facial Surgery Institute is not required to agree to your request if we feel it is in your best interest to use or disclose that information. However, if we do agree, we will comply with your request to restrict medical information unless that information is needed for emergency treatment.

An Accounting of Disclosures. You have the right to request an Accounting of Disclosures. This is a list of the disclosures of your health information Oral Facial Surgery Institute has made outside of our practice. Your request must be made in writing to the Practice Manager and must state the time period you want covered in the Accounting of Disclosure. You may not request information for any dates prior to April 14, 2003, the compliance date for the federal regulation, nor for a period more than six years in the past which would exceed our legal obligation to retain such records.

Your first request for a list of disclosures within a 12 month period will be free. If you request an additional list within 12 months of the first request, Oral Facial Surgery Institute may charge you a fee for the cost of providing the subsequent list. Oral Facial Surgery Institute will notify you of such costs and afford you the opportunity to withdraw your request before any costs are incurred.

Request Confidential Communications. You have the right to request how Oral Facial Surgery Institute communicates with you to preserve your privacy. For example – you may request that Oral Facial Surgery Institute call you only at your work phone number, or by mail at a special address or postal box. Your request must be made in writing and must specify how or where we are to contact you. Oral Facial Surgery Institute will accommodate all reasonable requests.

File a Complaint. If you believe Oral Facial Surgery Institute has violated your medical information privacy rights, you have the right to file a complaint with our Practice Manager or directly to the Secretary of Health and Human Services.

To file a complaint with our office you must submit the complaint in writing within 180 days of the suspected violation. Provide as much detail as you can about the suspected violation and send it to: Oral Facial Surgery Institute, Attn.: Office Manager, 621 S. New Ballas Road, Suite 16A, St. Louis, Missouri 63141. You should know that there would be no retaliation for your filing a complaint.

Uses or Disclosures Not Covered

Uses or disclosures of your health information not covered by this notice or the laws that apply to us may only be made with your written authorization. You may revoke such authorization in writing at any time and we will no longer disclose health information about you for the reasons stated in your written authorization. Disclosures made in reliance on the authorization prior to the revocation are not affected by the revocation.

For More Information

If you have any questions or would like additional information, you may contact our Practice Manager at: (314) 251-6725.

Effective Date: 04/14/09

The Oral Facial Surgery Institute has four convenient locations to meet your needs.