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.

Your rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get a copy of your dental and health records. You can ask to see or get an electronic or paper copy of your records and other health information we have about you. Ask us how to do this. We will provide a copy or a summary, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your records. You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say “no,” but we’ll tell you why in writing within 60 days.

Ask for confidential communications. You can ask us to contact you in a specific way (for example, your cell phone instead of your home phone) or to send mail to a different address. We will say “yes” to all reasonable requests.

Ask us to limit what we use or share. You can ask us not to use or share certain health information for treatment, payment or our operations. We are not required to agree, and we may say “no” if it would affect your care. If you pay for a service or item out of pocket in full, you can ask us not to share that information with your health insurer for payment or our operations. We will say “yes” unless a law requires us to share it.

Get a list of those we’ve shared information with. You can ask for a list (accounting) of the times we’ve shared your health information in the six years before the date you ask, who we shared it with, and why. It will include all disclosures except those for treatment, payment and health care operations, and certain others (such as any you asked us to make). We’ll provide one list a year for free, but we will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this notice. You can ask for a paper copy of this notice at any time, even if you have agreed to receive it electronically. We will give you a paper copy promptly. Ask us if you’d like this notice in large print.

Choose someone to act for you. If you have given someone medical power of attorney, or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority before we take any action.

File a complaint if you feel your rights are violated. You can complain if you feel we have violated your rights by contacting our Privacy Officer (below). You can also file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights online at ocrportal.hhs.gov, by calling 1-877-696-6775, or by writing to 200 Independence Avenue, S.W., Washington, D.C. 20201 (instructions at www.hhs.gov/hipaa/filing-a-complaint). We will not retaliate against you for filing a complaint.

Your choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations below, talk to us. Tell us what you want us to do, and we will follow your instructions.

You have both the right and the choice to tell us to: - share information with your family, close friends or others involved in your care, or in paying for it; - share information in a disaster relief situation.

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

We never share your information in these cases unless you give us written permission: - marketing purposes; - sale of your information; - most sharing of psychotherapy notes.

Appointment reminders. We may contact you by phone, voicemail, text message or email to remind you of appointments and to tell you about treatment you are due for. You choose which of these we use on our patient forms, and you can change your choice at any time.

Other messages from us. We may also use your contact information to send you newsletters, information and offers about our own services (such as our membership plan), birthday or holiday greetings, and requests to review your visit. You can ask us to stop any of these at any time. We never sell your information, and we never share it for another company’s marketing without your written permission.

Our uses and disclosures

How do we typically use or share your health information?

To treat you. We can use your health information and share it with other professionals who are treating you. Example: a specialist we refer you to, such as an oral surgeon, asks us for your X-rays and health history.

To run our practice. We can use and share your health information to run our practice, improve your care, and contact you when necessary. Example: we use your health information to manage your treatment and to check the quality of the care we give.

To bill for your services. We can use and share your health information to bill and get payment from health plans or other entities. Example: we give information about you to your dental insurance plan so it will pay for your services.

How else can we use or share your health information? We are allowed or required to share your information in other ways, usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.

• Help with public health and safety issues: preventing disease; helping with product recalls; reporting adverse reactions to medications; reporting suspected abuse, neglect or domestic violence; preventing or reducing a serious threat to anyone’s health or safety.
• Do research: we can use or share your information for health research.
• Comply with the law: we will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.
• Respond to organ and tissue donation requests, and work with a medical examiner or funeral director when an individual dies.
• Address workers’ compensation, law enforcement and other government requests: for workers’ compensation claims; for law enforcement purposes or with a law enforcement official; with health oversight agencies for activities authorized by law; for special government functions such as military, national security and presidential protective services.
• Respond to lawsuits and legal actions: in response to a court or administrative order, or in response to a subpoena.

Stricter laws. Some laws give certain information more protection than federal privacy law, for example Ohio’s law on HIV test results. When a stricter law applies, we follow it.

Substance use disorder treatment records. If we receive records about you from a federally assisted substance use disorder treatment program (covered by 42 CFR Part 2), we will not use or share those records, or testimony about what they contain, in any civil, criminal, administrative or legislative proceeding against you unless you give written consent, or a court orders it after you have been notified and given a chance to be heard. A court order allowing this must come with a subpoena or other legal requirement compelling the disclosure.

Information we share may be shared again. Information we share as this notice allows may be shared again by the person or organization that receives it, and may then no longer be protected by federal privacy law.

Our responsibilities

• We are required by law to keep the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time by letting us know in writing; this does not undo anything we already shared with your permission.

Changes to this notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available on request, in our office and on our website.

Questions or complaints

Privacy Officer: Dr. Gursharanjit Singh, DMD Modern Dental Concepts, 4817 Mahoning Ave NW, Warren, OH 44483 (330) 847-0676 · [email protected]

Effective date of this notice: December 1, 2026