Notice of Privacy Practices

Effective Date April 14, 2003

 This notice describes how health information about you and your child(ren)

 may be used and disclosed and how you can get access to this information. 

Our Commitment to Privacy

  You have entrusted the practice of Thomas D. Jusino D.D.S., M.S. with the

  responsibility of providing orthodontic care of you and your family.  We are

       dedicated to maintaining your trust.  We know that the privacy of your personal

       medical information is important to you.  That is why we take our responsibility

to protect the privacy of your personal medical information very seriously.

Uses and Disclosures of Health Information:

    We use and disclose health information about you for treatment, payment and

                        healthcare operations.  For example:

Treatment:  

   Obtaining past treatment information and medical/dental history about you or

                        your child(ren) and recording it in a health record.  During the course of

                        treatment, the Doctor may determine the need to consult with another

                        specialist, referring doctor or dentist, or primary care provider.

Payment:   

                        We may use and disclose your health information to obtain payment for

                        services we provide to you or your child(ren).

Required by law:

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

Appointment Reminders:

          We may use or disclose your health information to provide you with appointment

                        reminders (such as voicemail messages, postcards or letters).

Your Health Information Rights:

You have the right to:

       Ask for restrictions on the ways we use and give out information.  However, we

                       are not required to do so in every case.

  Request a paper copy of the Notice of Privacy Practices for Protected Health

                       Information.

                       Add information to your health record.

Complaints:

                           If you believe your privacy rights have been violated, you may contact the

  Privacy Officer at our office.  You may also 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 upon request.

                      We support your right to the privacy of your health information.  We will not

                      retaliate in any way if you choose to file a complaint with us or with the

                      U.S. Department of Health and Human Services.

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