NOTICE OF PRIVACY PRACTICES

BROOKE JORDAN DENTAL STUDIO

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.

I. Dental Practice Covered by this Notice

This Notice describes the privacy practices of Brooke Jordan Dental Studio (“Dental Practice”). “We” and “our” means the Dental Practice. “You” and “your” means our patient.

II. How to Contact Us/Our Privacy Official

If you have any questions or would like further information about this Notice, you can contact Brooke Jordan Dental Studio’s Privacy Official at:

Dr. Brooke Jordan
120 Doug Baker Blvd Ste 110
Birmingham, AL 35242
205-995-1450
jordandentalstudio@gmail.com

III. Our Promise to You and Our Legal Obligations

The privacy of your health information is important to us. We understand that your health information is personal and we are committed to protecting it. This Notice describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. Protected health information is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. This includes electronic protected health information (ePHI) stored or transmitted digitally.

We are required by law, including the Health Insurance Portability and Accountability Act (HIPAA) Privacy, Security, and Breach Notification Rules, to:

• Maintain the privacy and security of your protected health information;
• Give you this Notice of our legal duties and privacy practices with respect to that information;
• Notify you following a breach of unsecured protected health information; and
• Abide by the terms of our Notice that is currently in effect.

We adhere to the minimum necessary standard, meaning we will use, disclose, and request only the minimum amount of PHI needed to accomplish the intended purpose.

IV. Last Revision Date

This Notice was last revised on July 15, 2025.

V. How We May Use or Disclose Your Health Information

The following examples describe different ways we may use or disclose your health information. These examples are not meant to be exhaustive. We are permitted by law to use and disclose your health information for the following purposes without your authorization, unless otherwise noted:

A. Common Uses and Disclosures

1. Treatment. We may use your health information to provide you with dental treatment or services, such as cleaning or examining your teeth, performing dental procedures, or coordinating care. We may disclose health information about you to dental specialists, physicians, or other health care professionals involved in your care.
2. Payment. We may use and disclose your health information to obtain payment from health plans and insurers for the care that we provide to you.
3. Health Care Operations. We may use and disclose health information about you in connection with health care operations necessary to run our practice, including review of our treatment and services, training, evaluating the performance of our staff and health care professionals, quality assurance, financial or billing audits, legal matters, and business planning and development.
4. Appointment Reminders. We may use or disclose your health information when contacting you to remind you of a dental appointment. We may contact you by using a postcard, letter, phone call, voice message, text, or email. You have the right to opt out of receiving these communications by contacting our Privacy Official.
5. Treatment Alternatives and Health-Related Benefits and Services. We may use and disclose your health information to tell you about treatment options or alternatives or health-related benefits and services that may be of interest to you.
6. Disclosure to Family Members and Friends. We may disclose your health information to a family member or friend who is involved with your care or payment for your care if you do not object or, if you are not present, we believe it is in your best interest to do so, using our professional judgment.
7. Disclosure to Business Associates. We may disclose your protected health information to our third-party service providers (called “business associates”) that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use a business associate to assist us in maintaining our practice management software. All of our business associates are obligated, under contract with us, to protect the privacy of your information, comply with HIPAA, and are not allowed to use or disclose any information other than as specified in our contract.

B. Less Common Uses and Disclosures

1. Disclosures Required by Law. We may use or disclose patient health information to the extent we are required by law to do so. For example, we are required to disclose patient health information to the U.S. Department of Health and Human Services so that it can investigate complaints or determine our compliance with HIPAA.
2. Public Health Activities. We may disclose patient health information for public health activities and purposes, which include: preventing or controlling disease, injury or disability; reporting births or deaths; reporting child abuse or neglect; reporting reactions to medications or product defects or problems; notifying a person who may have been exposed to a disease; and notifying appropriate government authorities if we believe a patient has been a victim of abuse, neglect or domestic violence.
3. Health Oversight Activities. We may disclose your health information to health oversight agencies during the course of audits, investigations, inspections, licensure, and other proceedings related to oversight of the health care system.
4. Judicial and Administrative Proceedings. We may disclose your health information in the course of any administrative or judicial proceeding in response to a court or administrative order. We may also disclose information in response to a subpoena, discovery request, or other legal process if efforts have been made to notify you or obtain an order protecting the information.
5. Law Enforcement. We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes.
6. Deceased Persons. We may disclose your health information to coroners, medical examiners, or funeral directors consistent with applicable law to carry out their duties.
7. Organ Donation. We may disclose your health information to organizations involved in procuring, banking, or transplanting organs and tissues.
8. Research. We may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board or privacy board, provided it has waived the requirement for your authorization.
9. Serious Threat to Health or Safety. We may disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.
10. Specialized Government Functions. We may disclose your health information for military and veterans’ activities, national security and intelligence activities, protective services for the President and others, and correctional institutions or law enforcement custody situations.
11. Workers’ Compensation. We may disclose your health information as necessary to comply with workers’ compensation or similar laws.
12. Change of Ownership. In the event that Brooke Jordan Dental Studio is sold or merged with another organization, your health information/record will become the property of the new owner, although you will maintain the right to request that copies of your health information be transferred to another dental practice.

VI. Uses and Disclosures Requiring Your Specific Authorization

Other uses and disclosures of your PHI not described above will be made only with your written authorization. For example:

• Most uses and disclosures of psychotherapy notes (if applicable);
• Uses and disclosures for marketing purposes;
• Disclosures that constitute a sale of PHI; and
• Other uses and disclosures not described in this Notice.

You may give us written authorization to use or disclose your health information to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.

VII. Your Rights Regarding Your Protected Health Information

You have the following rights with respect to your PHI:

A. Right to Inspect and Copy. You have the right to inspect and obtain a copy (including an electronic copy if we maintain your records electronically) of your PHI contained in our designated record set for as long as we maintain it. We may charge a reasonable, cost-based fee for copies.

B. Right to Amend. If you feel that PHI we have is incorrect or incomplete, you may ask us to amend the information. We may deny your request under certain circumstances, but we will provide a written explanation.

C. Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we made of your PHI for purposes other than treatment, payment, health care operations, or for which you provided written authorization, for the previous six years.

D. Right to Request Restrictions. You have the right to request a restriction or limitation on the PHI we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the PHI we disclose about you to someone involved in your care or the payment for your care. We are not required to agree to your request except if the disclosure is to a health plan for payment or health care operations and pertains to a service for which you have paid out of pocket in full.

E. Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location (e.g., only by mail or at work). We will accommodate reasonable requests.

F. Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice, even if you have agreed to receive it electronically.

To exercise any of these rights, contact our Privacy Official in writing.

VIII. Breach Notification

In the event of a breach of your unsecured PHI, we will notify you as required by law. Depending on the circumstances, we may also notify the U.S. Department of Health and Human Services, the media, or other appropriate entities.

IX. Complaints

If you believe your privacy rights have been violated, you may file a complaint with us by contacting our Privacy Official or with the Secretary of the U.S. Department of Health and Human Services at www.hhs.gov/ocr/privacy/hipaa/complaints/. All complaints must be in writing. You will not be penalized or retaliated against for filing a complaint.

X. Changes to this Notice

We reserve the right to change the terms of this Notice and our privacy policies at any time. Any changes will apply to the PHI we already have. Before we make a significant change, we will promptly revise this Notice and post the new Notice in our office and on our website (jordandentalstudio.com). You can also request a copy of the revised Notice at any time.