Notice of Privacy Practices

This is a joint notice of the following affiliated practices, including all of their offices, doctors, staff and others who work under their direction:

• Behl Orthodontics, PLLC
• Madan Periodontics and Implant Dentistry, PLLC
• ICON Pediatric Dentistry and Orthodontics, PLLC
• ICON Dental Brands, PLLC, doing business as ICON Smile Studios

These practices may share your health information with one another as needed for treatment, payment and health care operations, as described in this notice and as permitted by law. Each practice is responsible for its own care. The practices are under common ownership or control and have designated themselves as a single affiliated covered entity under the HIPAA Privacy Rule (45 CFR 164.105(b)).

• We are required by law to maintain the privacy and security of your protected health information (“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.

Treatment. We use and share your information with other professionals who are treating you. Example: we send your records and X-rays to your general dentist or to an oral surgeon who is coordinating your care.

Payment. We use and share your information to bill and get payment from health plans or others. Example: we give information about your treatment to your dental insurance plan so it will pay for your braces or aligners, or to a payment-plan provider that you use.

Health care operations. We use and share your information to run our practice, improve your care and contact you when necessary. Examples: reviewing the quality of our care, training staff, and sending appointment reminders by phone, text or email.

For certain information, you can tell us your choices about what we share. If you have a clear preference, talk to us. In these cases, 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 payment for your care (for example, a parent or guardian who brings a child to appointments).
• 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 share your information if we believe it is in your best interest, and 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 and sale of your information.

We do not use your information for fundraising.

We are allowed or required to share your information in other ways — usually in ways that contribute to the public good. We have to meet many conditions in the law before we can share your information for these purposes:

• Public health and safety: preventing disease, reporting adverse reactions to medications or products, reporting suspected abuse, neglect or domestic violence, and preventing or reducing a serious threat to anyone’s health or safety.
• Research: under conditions set by law.
• Complying with the law: including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.
• Organ and tissue donation requests, and working with a medical examiner, coroner or funeral director.
• Workers’ compensation, law enforcement purposes, health oversight agencies for activities authorized by law, and special government functions such as military, national security and presidential protective services. If you are a member of the armed forces, we may share information as required by military command authorities.
• Lawsuits and legal actions: in response to a court or administrative order, or in response to a subpoena.
• Business associates: companies that perform services for us (for example our online forms, payment-plan and technology providers) may receive information only under a written agreement that requires them to protect it.

Virginia law, including the Virginia Health Records Privacy Act, may give you additional protections. When state law is more protective of your information than federal law, we follow state law.

When it comes to your health information, you have certain rights. To use any of them, contact our Privacy Officer, Chris Woidt, at (757) 224-3004 (fax (757) 351-3550), privacynotice@iconsmilestudios.com, or ICON Smile Studios and Affiliated Practices, Attn: Privacy Officer, 125 Independence Blvd, Suite 300, Virginia Beach, VA 23462.

• Get a copy of your health and claims records. You can ask to see or get an electronic or paper copy of your records. 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 if you think they are incorrect or incomplete. We may say “no,” but we will tell you why in writing within 60 days.
• Request confidential communications: you can ask us to contact you in a specific way (for example, a home or office 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 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 with whom we have shared your information (an accounting of disclosures) for up to six years before the date you ask, who we shared it with, and why — except for treatment, payment and operations and certain other disclosures. We provide one list a year for free and may charge a reasonable, cost-based fee for another within 12 months.
• Get a paper copy of this notice at any time, even if you agreed to receive it electronically.
• Choose someone to act for you: if you have given someone medical power of attorney, or someone is your legal guardian (including a parent of a minor patient), that person can exercise your rights. We will make sure they have this authority before we take any action.
• File a complaint if you feel your rights have been violated: contact our Privacy Officer, or file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by writing to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/. We will not retaliate against you for filing a complaint.

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 offices and on our website.

If you have questions about this notice, contact our Privacy Officer, Chris Woidt, at (757) 224-3004 (fax (757) 351-3550), privacynotice@iconsmilestudios.com, or ICON Smile Studios and Affiliated Practices, Attn: Privacy Officer, 125 Independence Blvd, Suite 300, Virginia Beach, VA 23462.