Notice of Privacy Practices

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

This notice will remain in effect until we replace it. We reserve the right to change our policy 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.

USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and health care operations.

We may use and disclose your health information to a physician or other health care provider providing treatment to you.

We may use or disclose your health information to a pharmacist who fills your prescriptions.

We may use or disclose your relevant health information to a laboratory that fabricates your prosthesis.

We may use or disclose your health information to obtain payment for services we provide to you. (Including third party payer, insurance company, and credit company or collection agency.)

We may use your health information in quality assessment, improvement activities, reviewing provider performance, and conducting training programs.

In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use you health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at anytime. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.

We may disclose your health information to a family member, friend or other person to the extent necessary to help you with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

We may use or disclose 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. In 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 health care. 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.

We may use or disclose your health information when we are required to do so by law.

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 of others.

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 institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

We may use or disclose you health information to provide you with appointment reminders (such as voice mail messages, postcards, or letters).

April 2003
Patient Rights
You have the right to look at or get copies of your health information, with limited exceptions. 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 below at the end of this notice. We will charge you a reasonable cost-based fee 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.

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 theses additional restrictions, but if we do, we will abide by our agreement (except in emergency).

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 requested.

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 roué request under certain circumstances.

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 have violated your privacy rights, or 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. If not satisfied, you also may submit a written complaint to the U.S. Department of Health and Human Services.

Attention: Advance Family Dental Care Privacy Officer

Telephone: (630) 357-2332

Address: 1567 North Aurora Rd., Suite 143
Naperville, IL 60563

April 2003