HIPAA Patient Privacy Practices

D and G DMD PLLC, d/b/a Smiles for Life
Notice of Privacy Practices for Protected Health Information
Effective Date: 02/16/2026

This notice describes how dental information about you may be used and disclosed and how you can get
access to this information. Please review it carefully!

In accordance with federal privacy laws, this dental office is authorized to use and disclose your health information for purposes related to treatment, payment, and healthcare operations. Protected Health Information (PHI) consists of information created or obtained by this dental office in the course of providing care to you. This information may include, but is not limited to, documentation of symptoms, examinations, diagnostic test results, diagnoses, treatment plans, and requests for future care or treatment. PHI also includes billing and payment records associated with these services.

In the course of providing your treatment, the dentist may consult with another specialist when medically
appropriate.

Example of Use of Your Health Information for Payment Purposes:

We submit claims for payment to your health insurance provider. In connection with these claims, the insurance
provider—or another business associate assisting with payment—may request information regarding the dental
services provided.

Example of Use of Your Information for Health Care Operations:

We obtain certain services from our insurers and other business associates, including quality assessment and
improvement, outcomes evaluation, development of clinical protocols and guidelines, training programs,
credentialing, medical review, legal services, and insurance-related functions. To obtain these services, we may
disclose relevant Protected Health Information (PHI) about you to such insurers or business associates as necessary.

Your Health Information Rights

The health and billing records maintained by this dental office are the physical property of the dental office.
The information contained in these records, however, belongs to you. You have the right to:

• You have the right to ask us to limit how your health information is used or shared. Submit your request in writing to our dental office. Although we are not obligated to approve every request, we will follow any restrictions that are granted.
• You may request a restriction on the disclosure of your health information to a health plan for payment or
  healthcare operations purposes, provided that the request does not involve treatment and the information relates
  solely to a healthcare service for which you have paid in full out-of-pocket. The dental office is required to comply
  with such a request.
• You have the right to receive a paper copy of the current Notice of Privacy Practices for Protected Health
  Information (“Notice”) by submitting a request at our dental office.
• You have the right to request access to inspect and obtain copies of your health and billing records. This right may be exercised by submitting a written request to our dental office.
• You have the right to appeal any denial of access to your Protected Health Information, except in certain limited
  circumstances as permitted by law.
• You have the right to request that your health care record be amended to correct incomplete or inaccurate
  information by submitting a written request to our dental office. We may deny your request if the information you
  wish to amend is not part of the record, was not created by us (unless the originator is unavailable), is not part of
  the information you are permitted to inspect, or is deemed accurate and complete
• The information was not created by our dental office, unless the person or organization that created it is no longer available to make the requested change.
• The information is not part of the health information maintained by or on behalf of the dental office. • The
  information is not part of the health information to which you are permitted to inspect and copy; or
• The information is already considered accurate and complete.
• If your request is denied, we will inform you of the reason and allow you to submit a statement of disagreement,
  which will be kept with your records.
• You have the right to request that communications regarding your health information be made by alternative
  means or sent to an alternative location. Such requests must be submitted in writing to our dental office.
• You may obtain an accounting of disclosures of your health information, as maintained by law, by submitting a
  formal request to our dental office. Please be advised that this accounting shall not include disclosures made for the purposes of treatment, payment, or healthcare operations. Furthermore, it excludes disclosures made directly to you or at your request, those made pursuant to a signed authorization, or information shared for facility directories and notifications to family members or friends regarding your care, location, or status.
• You may revoke any previous authorizations for the use or disclosure of your information by submitting a written
  revocation to our dental office. Please note that such a revocation will not apply to any information already
  disclosed or actions already taken based on your prior authorization.

Our Responsibilities

Our dental office is mandated under law to:

• Uphold the privacy standards for your health information as prescribed by federal and state law; • Provide a
  comprehensive disclosure of our organizational responsibilities and privacy practices concerning the management
  and protection of your personal information; • Adhere to the specific terms and conditions set forth in this Notice of Privacy Practices;
• Provide formal notification should it be determined that a requested restriction or specific
  request cannot be fulfilled; and,
• Accommodate reasonable requests pertaining to the modalities and channels
  through which your health information is communicated.

We reserve the right to modify, amend, or rescind any provision of our privacy and access practices and to
implement new policies regarding the protected health information under our care. In the event of a material change
to our information practices, we will revise this Notice accordingly. You maintain the right to obtain a revised copy
of the Notice upon request by contacting our office via telephone or by visiting our facility in person.

Substance Use Disorder Information

Records pertaining to substance use disorder diagnosis (medical cases), treatment, or referral are afforded heightened protections under federal law. This sensitive information will be withheld from use or disclosure
without your prior authorization, with the exception of limited circumstances where such actions are legally
required or authorized by statute.”

Information regarding substance use disorders may be shared for treatment, payment, and health care operations, or
in accordance with federal regulations, including legal mandates and instances involving the prevention of
significant threats to health or safety. Any use or disclosure of this sensitive information will be conducted in full compliance with the procedural requirements set forth by federal confidentiality laws.

You are entitled to request limitations on the use and disclosure of your substance use disorder records and to
receive a formal accounting of disclosures in accordance with statutory requirements.”

To Request Information or File a Complaint

For further clarification or to submit a formal report pertaining to our information handling practices, please direct your communication to 540-828-2312.

In the event you believe your privacy protections have been breached, you may lodge a written grievance with our
facility by submitting it to 115 Oakwood Drive Bridgewater, VA 22812. Additionally, formal complaints may be
directed to the Secretary of Health and Human Services.

We shall not, under any circumstances, demand that you forgo your right to submit a complaint to the Secretary of
Health and Human Services as a condition of your care or treatment.

This facility maintains a strict prohibition against any form of retaliation toward individuals who elect to file a complaint with the Secretary of Health and Human Services.

Other Disclosures and Uses

In accordance with our best clinical judgment, this facility may release limited health information to family
members or other designated persons involved in your care or in the payment for such care. These disclosures are
permitted when you have not raised an objection or when emergency conditions necessitate the sharing of
information to ensure the continuity of your health and safety.
You may add what fact matters or find the HIPAA consent, who has full access and who has partial access.

Notification

• Absent an objection from you, we may utilize or disclose protected health information to apprise, or assist in the
notification of, a family member, personal representative, or another individual responsible for your care regarding
your current location, general clinical status, or in the event of your death.

Disaster Relief

• Your Protected Health Information (PHI) may be used or shared to support disaster relief activities when needed.

Food and Drug Administration (FDA)

• Your Protected Health Information (PHI) may be shared with the FDA concerning adverse events related to food,
supplements, or other products, or regarding product defects and post-marketing surveillance, to support product
recalls, repairs, or replacements.

Workers Compensation

• In instances where you are seeking benefits under Workers’ Compensation, we may disclose your protected health
information as required to maintain compliance with relevant Workers’ Compensation statutes and regulations.

Public Health

• We are permitted by law to release protected health information to public health authorities and legal bodies
responsible for public safety and disease surveillance. Such disclosures are conducted for purposes including the
monitoring of drug reactions, addressing product issues, managing recalls, and notifying persons who may have
been exposed to a contagious disease or who represent a risk for spreading a condition.”

Abuse & Neglect

• As permitted by law, this facility may disclose protected health information to the appropriate governmental or
public authorities for the purpose of reporting suspected instances of abuse or neglect.

Employers

• Protected health information may be released to your employer exclusively when services are requested by them
to conduct evaluations regarding medical surveillance of the workplace or to assess work-related health conditions.
Upon such release, we shall furnish you with a written notification. Outside of these specific regulatory exceptions,
no health information will be shared with your employer without your express written authorization.

Correctional Institutions

• In the event of your incarceration, this office is authorized to release protected health information to the
correctional institution or its representatives to facilitate your healthcare. Furthermore, information may be shared
when deemed essential to maintain the collective health and safety of the inmate population and facility personnel.

Law Enforcement

• We may disclose your protected health information for law enforcement purposes as mandated by law. This
includes, but is not limited to, compliance with judicial orders, proceedings involving felony prosecutions, or
instances where an individual is in the legal custody of law enforcement officials.

Health Oversight

• Pursuant to federal regulations, we may disclose your protected health information to authorized health oversight
agencies for activities mandated by law. These oversight functions include audits, investigations, inspections, and
licensure necessary for the government to monitor the healthcare delivery system and regulatory compliance.

Judicial/Administrative Proceedings

This office may disclose protected health information during judicial or administrative proceedings as permitted or
mandated by law. Such disclosures may occur upon receipt of your express authorization or in strict accordance
with a valid court order.

Serious Threat

• In compliance with applicable legal frameworks, this office may disclose protected health information when
deemed necessary to avert a serious and imminent threat to health or safety. Such disclosures are conducted in a
manner consistent with law to prevent or diminish the risk to the health or safety of an individual or the community
at large.

For Specialized Governmental Functions

• In accordance with legal authorizations, we may release protected health information to facilitate specialized
government operations. Such instances may involve disclosures to military command authorities for personnel
health assessments, to federal officials for national security purposes, or to the appropriate agencies responsible for the management of public assistance programs.

Coroners, Medical Examiners, and Funeral Directors

• We are authorized to release health information to coroners or medical examiners as required for the performance
of their legal mandates, including death investigations. Furthermore, relevant health information may be shared
with funeral directors to facilitate the fulfillment of their responsibilities regarding deceased patients.

Other Uses

• Any uses or disclosures of your protected health information not specifically described in this Notice will be made
only when required by law or upon receipt of your express written authorization. You maintain the right to revoke
such authorization at any time, as detailed in the ‘Your Health Information Rights’ section of this Notice, except to
the extent that action has already been taken in reliance on it.

Website

• If an entity website is maintained, the full text of this Notice of Privacy Practices will be accessible on that
platform to ensure transparency regarding our data handling procedures

PRIVACY AND SECURITY OFFICIAL NAME AND CONTACT INFORMATION
Privacy and Security Official Name: Tara Kenney
Telephone: 540-828-2312
Address: 115 Oakwood Drive Bridgewater, VA 22812
Email: smiles@smilesforlifeonline.com