THIS NOTICE DESCRIBES HOW HEALTH 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 maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect February 16, 2026 and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law, and to make new Notice provisions effective for all protected health information that we maintain. When we make a significant change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at our practice location, and we will provide copies of the new Notice upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

We may use and disclose your health information for different purposes, including treatment, payment, and health care operations. For each of these categories, we have provided a description and an example. Some information, such as HIV-related information, genetic information, alcohol and/or substance use disorder treatment records, and mental health records may be entitled to special confidentiality protections under applicable state or federal law. We will abide by these special protections as they pertain to applicable cases involving these types of records.

Treatment. We may use and disclose your health information for your treatment. For example, we may disclose your health information to a specialist providing treatment to you.

Payment. We may use and disclose your health information to obtain reimbursement for the treatment and services you receive from us or another entity involved with your care. Payment activities include billing, collections, claims management, and determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party. For example, we may send claims to your dental health plan containing certain health information.

Healthcare Operations. We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, conducting training programs, and licensing activities.

Individuals Involved in Your Care or Payment for Your Care. We may disclose your health information to your family or friends, or any other individual identified by you when they participate in your care or in the payment for your care. Additionally, we may disclose information about you to a patient representative. If a person has the authority by law to make health care decisions for you, we will treat that patient representative the same way we would treat you with respect to your health information.

Disaster Relief. We may use or disclose your health information to assist in disaster relief efforts.

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

Public Health Activities. We may disclose your health information for public health activities, including disclosures to:

• Prevent or control disease, injury or disability.
• Report child abuse or neglect.
• Report reactions to medications or problems with products or devices.
• Notify a person of a recall, repair, or replacement of products or devices.
• Notify a person who may have been exposed to a disease or condition; or
• Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.

National Security. We may disclose to military authorities the health information of Armed Forces personnel

under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement officials who have lawful custody the protected health information of an inmate or patient.

Secretary of HHS. We will disclose your health information to the Secretary of the U.S. Department of Health and Human Services when required to investigate or determine compliance with HIPAA.

Worker's Compensation. We may disclose your PHI to the extent authorized by and to the extent necessary to comply with laws relating to worker's compensation or other similar programs established by law.

Law Enforcement. We may disclose your PHI for law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order.

Health Oversight Activities. We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and credentialing, as necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Judicial and Administrative Proceedings. If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process instituted by someone else involved in the dispute, but only if efforts have been made, either by the requesting party or us, to tell you about the request or to obtain an order protecting the information requested.

Research. We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information.

Coroners. Medical Examiners and Funeral Directors. We l may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors consistent with applicable law to enable them to perform their duties.

Fundraising. We may contact you to provide you with information about our sponsored activities, including fundraising programs, as permitted by applicable law. If you do not wish to receive such information from us, you may opt out of receiving the communications

SUD (substance use disorder) Treatment Information

If we receive or maintain any information about you from a substance use disorder treatment program that is covered by 42 CFR Part 2 (a “Part 2 Program”) through a general consent you provide to the Part 2 Program to use and disclose the Part 2 Program record for purposes of treatment, payment, or health care operations, we may use and disclose your Part 2 Program record for treatment, payment, and health care operations purposes as described in this Notice.

If we receive or maintain your Part 2 Program record through specific consent you provide to us or another third party, we will use and disclose your Part 2 Program record only as expressly permitted by you in your consent.

In no event will we use or disclose your Part 2 Program record, or testimony that describes the information contained in your Part 2 Program record, in any civil, criminal, administrative, or legislative proceedings by any Federal, State, or local authority against you, unless authorized by your consent or by a court order after you are provided notice of the order.

OTHER USES AND DISCLOSURES OF PHI

Your authorization is required, with a few exceptions, for disclosure of psychotherapy notes, use or disclosure of PHI for marketing, and the sale of PHI. We will also obtain your written authorization before using or disclosing your PHI for purposes other than those provided for in this Notice (or as otherwise permitted or required by law). You may revoke authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already acted in reliance on the authorization.

YOUR HEALTH INFORMATION RIGHTS

Access

You have the right to look at or obtain copies of your health information, with limited exceptions. Your request must be in writing. 

You may obtain a form to request access using the contact information listed at the end of this Notice, or you may send a letter to the address provided.

If you request information that we maintain on paper, we may provide photocopies. If you request information that we maintain electronically, you have the right to receive an electronic copy.

We will provide the form and format you request if it is readily producible.

We may charge a reasonable, cost-based fee for supplies, labor, and postage if copies are mailed. Contact us for an explanation of our fee structure.

If you are denied access, you have the right to have the denial reviewed in accordance with applicable law.

Disclosure Accounting

With certain exceptions, you have the right to receive an accounting of disclosures of your health information.

To request this, you must submit your request in writing to the Privacy Official. If you request this more than once in a 12-month period, we may charge a reasonable, cost-based fee.

Right to Request a Restriction

You have the right to request additional restrictions on our use or disclosure of your PHI. Requests must be submitted in writing to the Privacy Official and must include: (1) What information you want limited, (2) whether you want to limit use, disclosure, or both and (3) to whom the limits apply. We are not required to agree to your request, except when the disclosure is to a health plan for payment or health care operations and the item or service has been paid in full by you or someone on your behalf (other than the health plan), has paid our practice in full.

Alternative Communication

You have the right to request that we communicate with you by alternative means or at alternative locations. Your request must be in writing and must explain alternative means or location and how payment will be handled. We will accommodate reasonable requests. If we cannot reach you using the requested method, we may use the information we have.

Amendment

You have the right to request that we amend your health information. The request must be in writing and explain why the amendment is needed. We may deny your request in certain circumstances. If we deny it, we will provide a written explanation and inform you of your rights. If we agree to your request, we will amend your records and notify you of such.

Right to Notification of a Breach

You will be notified of breaches of your unsecured protected health information as required by law.

Electronic Notice

You may request a paper copy of this Notice at any time, even if you agreed to receive it electronically.

QUESTIONS AND COMPLAINTS

If you would like more information about our privacy practices or have questions, please contact us.

If you believe your privacy rights have been violated, or disagree with a decision we made regarding access, amendment, restrictions, or alternative communication, you may file a complaint with us using the contact information above.

You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide the address upon request.

We support your right to privacy and will not retaliate if you file a complaint.

 

PRIVACY OFFICIAL — CONTACT INFORMATION

Privacy Official Name: Yelena Chuvashova

Telephone: (425)651-6000

Fax: (425)677-8287

Address: 240 NW Gilman Blvd., Ste 7., Issaquah, WA 98027

Email: birchdentistry@gmail.com