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.

We are required by law to make this notice. This notice describes the information practices of Dr. Mark Conover and its employees.

I. How we may disclose medical information about you. In all cases in this document the term “medical information” includes medical and dental information. The following categories explain examples of uses of your information. The examples are not meant to be inclusive, but all disclosures will fall into one of these listed categories.

a. For treatment: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to employees involved in taking care of you. For example, an assistant might need to know your symptoms in order to take an X-ray of the affected area. We may also need to disclose medical information about you to others outside our facility, such as other physicians who may be involved in your medical care, or pharmacies filling your prescriptions.

b. For Payment: We may use and disclose medical information about you so that the treatment and services you receive at our facility may be billed to and payment may be collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about surgery you received so your health plan will pay us or reimburse you for the surgery. We may also tell a health plan about a treatment you are going to receive in order to obtain prior approval or determine whether your plan will cover your treatment.

c. For Health Care Operations: We may use and disclose medical information about you for office operations. These uses and disclosures are necessary to run the office and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may also combine medical information about many office patients to decide what additional services our office should offer, what services are not needed, and whether certain new treatments are needed. We may also disclose information to other employees for learning purposes.

d. Appointment reminders: We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at our office.

e. Treatment Alternatives: We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

f. Health Related Benefits: We may use and disclose medical information to tell you about health related benefits or services that may be of interest to you.

g. Individuals Involved in your Care or Payment for your Care: We may release medical information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. Unless there is a specific written request from you to the contrary, we may also tell your family or friends your condition and that you are under our care.

h. Research: Under certain circumstances we may use and disclose medical information about you for scientific purposes. For example, a study project may involve comparing the success rates of certain dental implants over a period of time. In these cases your personally identifying information will have been removed.

i. As Required by Law: We will disclose medical information about you when required to do so by federal, state, or local law.

j. Workers Compensation: We may release medical information about you for workers’ compensation or similar programs. These programs provide benefits for work related injuries or illness.

k. Legal Actions: If you are involved in a lawsuit or a dispute, we may disclose information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only after the minimum time allowed by the subpoena or other request has passed in order to give you or your attorney time to oppose the request. We may also disclose medical information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons, or similar process, or in any other case where we are required to do so by law.

l. Public Health Risks: We may disclose information about you to notify the appropriate governmental authority if we believe a patient has been the victim of abuse, neglect or domestic violence, where this disclosure is required or authorized by law.

II. Your Rights Regarding Medical Information About You: You have the following rights regarding medical information we maintain about you.

a. Right to Inspect and Copy: You have the right to inspect and receive a copy of medical information that may be used to make decisions about your care, including billing records. To inspect and receive a copy of medical information that may be used to make decisions about you, you must submit your request in writing to our office in which you were treated. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.

b. Right to Amend: If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for us. An amendment must be made in writing and submitted to our office in which you were treated.

c. Right to an Accounting of Disclosures: You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you other than those described above. To request this list or “accounting of disclosures”, you must submit your request in writing to our office in which you were treated. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within a 12 month period will be free. For additional lists, we may charge you for the cost of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

d. Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or payment for your care. For example, you could ask that we not use or disclose information about a surgery that you had. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is required to provide you with emergency treatment. To request restrictions, you must make your request in writing to our office in which you are treated. 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, for example, disclosures to your spouse.

e. Right to Request Confidential Communication: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. To request confidential communications, you must make your request in writing to the office in which you are treated. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

f. Right to a Paper Copy of this Notice: You have a right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive a copy of this notice electronically, you are still entitled to a paper copy. You may obtain a copy of this notice at our website, www.drconover.com. To obtain a paper copy of this notice, ask at any of our offices.

III. Changes to this notice: We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the office. The notice will contain, on the first page in the top right corner, the effective date. In addition, each time you return to our office for a different course of treatment, we will offer you a copy of the current notice in effect.

IV. Complaints: If you believe your privacy rights have been violated, you may file a complaint with the office or with the Secretary of the Department of Health and Human Services. To file a complaint, you must submit it to our office where you received treatment in writing.

V. Other Uses of Medical Information: Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care we have provided to you.

VI. Questions: If you have any questions about this notice, please contact the office in which you were treated.