Privacy Practices

Lucille Dental, LLC

NOTICE OF PRIVACY PRACTICES

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.

THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We
are also required to give you this Notice about our privacy practices, our legal duties, and your rights
concerning your health information. We must follow the privacy practices that are described in this Notice
while it is in effect. This Notice takes effect 03-01-2003, 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. We reserve the right to make the changes in our privacy
practices and the new terms of our Notice effective for all health information that we maintain, including
health information we created or received before we made the changes. Before we make a significant
change in our privacy practices, we will change this Notice and make the new Notice available 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.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and healthcare operations. For
example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider
providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to
you.

Healthcare Operations: We may use and disclose your health information in connection with our
healthcare operations. Healthcare operations include quality assessment and improvement activities,
reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider
performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare
operations, you may give us written authorization to use your health information or to disclose it 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. Unless you give
us a written authorization, we cannot use or disclose your health information for any reason except those
described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient
Rights section of this Notice. We may disclose your health information to a family member, friend or other
person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if
you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification
of (including identifying or locating) a family member, your personal representative or another person
responsible for your care, of your location, your general condition, or death. If you are present, then prior to
use or disclosure of your health information, we will provide you with an opportunity to object to such uses
or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health
information based on a determination using our professional judgment disclosing only health information

that is directly relevant to the person’s involvement in your healthcare. We will also use our professional
judgment and our experience with common practice to make reasonable inferences of your best interest in
allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health
information.

Marketing Health-Related Services: We will not use your health information for marketing
communications without your written authorization.

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

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably
believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other
crimes. We may disclose your health information to the extent necessary to avert a serious threat to your
health or safety or the health or safety of others.

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 official having lawful custody of protected health information of
inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with
appointment reminders (such as voicemail messages, postcards, or letters).

PATIENT RIGHTS

Access: You have the right to look at or get copies of your health information, with limited exceptions. You
may request that we provide copies in a format other than photocopies. We will use the format you request
unless we cannot practicably do so. (You must make a request in writing to obtain access to your health
information. You may obtain a form to request access by using the contact information listed at the end of
this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time.
You may also request access by sending us a letter to the address at the end of this Notice. If you request
copies, we will charge you $.30 for each page, $15.00 per hour for staff time to locate and copy your health
information, and postage if you want the copies mailed to you. If you request an alternative format, we will
charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a
summary or an explanation of your health information for a fee. Contact us using the information listed at
the end of this Notice for a full explanation of our fee structure.)

Disclosure Accounting: You have the right to receive a list of instances in which we or our business
associates disclosed your health information for purposes, other than treatment, payment, healthcare
operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this
accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for
responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of
your health information. We are not required to agree to these additional restrictions, but if we do, we will
abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with you about your
health information by alternative means or to alternative locations. {You must make your request in
writing.} Your request must specify the alternative means or location, and provide satisfactory explanation
how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. (Your request must be
in writing, and it must explain why the information should be amended.) We may deny your request under
certain circumstances.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled
to receive this Notice in written form.

QUESTIONS AND COMPLAINTS-Contact our contact officer: Dr. GurrIf 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, or you disagree with a decision we
made about access to your health information or in response to a request you made to amend or restrict the
use or disclosure of your health information or to have us communicate with you by alternative means or at
alternative locations, 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
provide you with the address to file your complaint with the U.S. Department of Health and Human Services
upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you
choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact Officer: Dr. Gurr

Telephone: (907)376-5207

110 E. Swanson Ave

Wasilla, AK 99654