Our Legal Duty

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.

Uses and Disclosures of Health Information

We may use and disclose your health information for different purposes, including treatment, payment, and health care operations. Treatment: 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 treatment and services. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations.

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

Patient Rights

Access: You have the right to look at or get copies of your health information, with limited exceptions. Disclosure Accounting: You have the right to receive an accounting of disclosures of your health information in accordance with applicable laws. Right to Request a Restriction: You have the right to request additional restrictions on our use or disclosure of your PHI. Amendment: You have the right to request that we amend your health information. Right to Notification of a Breach: You will receive notifications of breaches of your unsecured protected health information as required by law.

Questions and Complaints

If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will not retaliate in any way if you choose to file a complaint.

Privacy Authorization

This Authorization is required by the privacy regulations promulgated by the United States Department of Health and Human Services. Your Protected Health Information (PHI) will be disclosed to the following people: all employees of this office. The information used or disclosed per this Authorization may be subject to redisclosure by the recipient(s), and thus, no longer protected by the privacy rules.

By signing this form, you agree that you understand that all charges for orthodontic treatment are due and payable at the time services are rendered, unless prior arrangements have been made. By signing this form, you also agree to authorize insurance benefits to be paid directly to our practice.

You agree that insurance portions are ESTIMATED based on information released by your insurance company. However, the estimated amount of insurance is NOT a guarantee of payment. You are aware that insurance is a contract between yourself and your insurance carrier/provider. As a courtesy, claims may be filed on your behalf. If for some reason the insurance does not cover the benefit we have estimated, that difference will become the responsibility of the patient/parent/guardian.

You understand that you are financially responsible to the doctor(s) for all treatment.

Returned checks will result in a $35.00 charge to your account.

Video recording is strictly prohibited.

I hereby acknowledge that I have been advised that photographs and images will be taken of me or my child, beforehand, during and after procedures. The photographs will be taken by one of the members of our office. I hereby acknowledge that photographs may be taken during my, or my child's, time in our office. I hereby give my consent for this office to use the photographs under the following circumstances: lectures, research, publications, internet advertising, on our website, on our social media outlets, or in any print advertising.

I grant this office and its employees, legal representatives, and associates the irrevocable and unrestricted right to use and publish photographs or video footage of me, or imagery in which I may be included, for editorial, trade, advertising, and web use. I also grant this office the right to alter any images or photographs without restriction and without my inspection or approval. I hereby release this office and their legal representatives from all claims and liability relating to said imagery.

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my child's medical status.

I hereby authorize the release of any information pertaining to my child\'s medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance.

I understand that where appropriate, credit bureau reports may be obtained.

Any photos, x-rays, and images taken are for office use only and will be shared with the dentist and any specialist referrals required.