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, :(Jl:lf£alp .f",,~ily .Dantistry~f.--:::~_ + "r - ,;,.~:: .~. "

, ,': :'~:;.:;: 0 ':, Buf€alo, MN .S53 13:7: ::'" :,")'"'''~' ';7763 '. ~E 'rr6;3) ~6'82-453'4 ' .

N{S~'I,e:~p,grf.l~~PR4;VAQ¥c:_A.• e.~liGES",",.. ,.THISNOTICE~D,ESCRIBES;H~\y:HI¥.ALTI,jJNFQfJ,PJlATIOtii ABOl,lT X9lJ M~!BE U~~Q .AN[),

DISCLOSED AND HOW YOU CAN GET ACCESS TO THISINFORMATIO,,.,..•.'--t..;' ,..'.,.'

-::'.'. ;, ;PLE~~E REMIEvv.rr:'.:~:AR~~Q.LLY; ;< ",,' "

'T.HeE ,PRIVACY QF.YOt!,lR'HEALl1H INFqJI:M~TlqNJSIMPQr;p~Ar'fT.T9, US.; c

q~J(i~Ii~_A~'DltrY. '" "', <,' .. ,', ,'''''' ',',"" " " ;.~.~,,;,,' , ""., 'l/1.e,arerequJi:ed'b,y:applicatil~J(;}:cre(aland ,stat~.Iav(,!o 'l1'l~inf!iiiMItEi";Riiyacipf.y.Qorh~altfi":inf~im~tion:We 'arealsoro~~1i~~~AQ:~ly~'you,m!s,N:QtlcJi;~~?~L~~KP:1~~~Y~Ji~~~iq~~t?~~]~~~!:~~M~\~'.~n~.~~a,C~~~~s,(:~h?eihi~g'yp~r:tiealt~,l(lt~I1T:!~JI~.(I,;Wel'!lu~tf<?llowthepflyqcypra9.~p~~~hEltElr~:cll~s§n;~~dJI1·tl1l:s"Nbbce;YiJ~I!e'lt'lsIn effect. This Notlce,take'seffecfa'4JJ5Y;2~b,3',and will remaio In eff'€c'f iirttUwe' repicice'it.'· ";. ",~ .." '0:.,. " '.

< ,<:_ ~~~"'/' !::;v ~ >~ y;'I, :-, ~ _,:: "I, '~ './.<.. ~ , ''" rf~:;.y.

We 'rest;lr'vetKeright~19change"oorprivacijipractic'ElSiShdthe,t'Elti'11s.;'dt~this'Notice'atany:,tir:ne;:provid~d!Such,cliang-esare p~!ii1iittEld,by applicable law. We reserve the righUo makethe changesincour privacy practices and the new teims

·,orOtiji;Notice,'effe'~tiyeAorall"'i'Elalth':inforlTiali.on~tMtwe,maintain, includin:gO.ealthil'lfermation we create9 or rece~vedbefore'wetm~dethe.:cl:ianges.,~efore:we;make'a sj§!'IitiG§lnt,chang~inourj;)iv~cY'p!actice~; we will.cha'nge'thl~NotiGea,nemakethe new Notice avallableupcnrequest, '! ' '";, ' , "'0 ,CO"

You m!ly.'r~qoesta 'copy ofour: Notice at~~yiirrte:;P:'or!mdr~j-it'1f6rrha:tiCi'n.'abouf':6i:ir;pfivacy.practice~;Otfor adeitionalcople$ of this Notlqg, please contact us'using the.iljf6rl11ationlistedat.fhe endot this Notice.

;) .-./ >'.'.'. '". '/ ',."., .•...y< , '

;USESCA'~:DDIS6Lo§URES'bFIiEALTH7:iNF&~MATI6N: , ,We use'and dlsclose.health lntormatlonabout youtortreatment, payment, and healthcare operafions:Fbrexample:

'Tfeatment:We may -use or disclose yourhealth ihformatitm to' a physician or other healthcare provider'providiJ;lgtreatment-to-you. ..' .

,'<--c,/ ' ',"',,< ," ' , , , ',' ,,'-':,,; :-' .'.' ",' '''':'.' ,;" ';',',payn"fent:'We may use and discloseyour health informationto obtain'payment tor.services we prqVideyou., ..,'. .... .~.. .', '" ,-.- . ";. ... .'..,

Healtl1cateQpel'ations: We may use and .discleseyotuhealth information in connection. with our .healthcar'e· 0~Ejfatioils;f'ieaifhcareqpen,itions Include quality assessment'and'iml'rovement activities; reviewing,.the,comfileteneeOf.qu~dificaHons6f,health'care 'pf6fessionals; 'evahJatihg:ptactititmet ,~rid':pr'oviderperlormaoce{ condueting t(ainingprograms.nccreditatlon, certification, licensinq.or credentialil19'activities. c •

YOUr"A~th~;i%ation: In ~dditiont; our use o(your he~lthi'nforri.~ti0n for treatment, iayrl,enf or healtJlca~~:~p~~';~iidriS,yO!J.maygive us\'{rt~tenauthorization ~ouse your h~alth information or to disclose it to anyonef~ra:ny purpdse.)f yo~,glyeUS,an authOtizaf.ion,you may revoke i(jnwfitirigat a-nytime.,yourrevocation....,inootaffe8te':iy,~$~ ot'9.i~~,19sIilr~spf:}rrTlittedby yqut,autbori?~1iOnwhileit .'Alasin effect lJnlassyougive. usa written"authotiZ:ation',We.cimnot:use<ordiscloseyoiir health fn.ohti~tibbfor'ahY ,rea:son·ej(ce~tJK'0'¥e.d~scribed{ii1tl)isN~tice." '" " " .-' .

·ToYour<oFamilyand·Fi'iends: Wefmust;di~dQsEryq..brJ:l.ealth~ioJor'ma,tjOl'k.tO;yo.U,as>desqripe,q)n.the Patielj,tPijghts's.ectionof tnis,Notice,We rnay discloSe:y.burhealth,irlf.Or:l'T:1..~tjol;ltQ~3lqmUy;;(rtE:lrnber,frieh~10r,o~h.:er"p,~rs.o!l,totl:i~"efde:l1tneC'e$S~I¥',tcVl:relp~~th,yot.lr.ha~ltI!lC,~re.or.with:p?y,tn;ent~f0r;)iourlie.aJ~~ca,t~,'bLJtoplyit yo~~~g~ee;;tfialw,~rna.Ydo,s:o.

"B~r~p,~~IQ}l~~¥~.9In ,Care: wefrl~yu~e .O(9iicr6~e,healthinf?rlTl~tio;~~~,n~ti(i,<?r'assiftin':th~;:h~tifk:ation,of" (il1C1uaitig'identitYirlgorlocating) a familyinember,y<?urpersonalrep~esentative'ibr:'arit>th~-rpersonresportsil:lle:forY0ar

,c~re,o(your location, your general;fondition, or death.•,Jf,yotJare'preseht;'fl'i-en;:pridttouse ordisclosure of yotntieaithinformation,we will .provide YOIi'with an opportuJJiWto object to such uses or disclosures. In the event of yourincapacItY,0rc:em~rgency circumstances, we Wilrdi$cl0S~;healfh' lntormatton.based ona/'€IeteJmin<:l~(jnusillg,ourpretesslonal judgment disclosing 0nlyhealth,il'l,f~r.mation'thati$~direc::tly,;rel~vant"to.me .,p~rlSOtl:s'inxolvementir;l',your ,~"heallhcare. We"WiII,alsouse our professional jjJQ9mentand our experiencewith commoh.practice to make reasonableinferences of your best interest in allowing a person to pick upfiUedpres~~ptions, rn.,edic,alsuppliEls,x-rays, or othersimilar'fbrmsofhealth lntorrnation. ' '.,' '".' ' , '

MarketIJlgtl~aJth·Related Sef.V.ices::We'~wilt,m6fusesyour he:allh,jIiJormationfor mar:ketingcOlllmupications Withoutyourwrittenauthorization. ' . '

Required by LSw: We may use brClis6l6secY:Q\Jr~ealth:Iilfoimation when we are requirea byJaw,to do 'so by law~

Abuse:orNeglect: We.may .disclese your healthil'lformati<)n,toapp'rop,ril!liesatithC:5iiti~sif,;we'rea~phably,believe "Watyou area possible victim of abuse, neglectjor domesfibviole!l~e or the possible victim of other crimes. We maydlsoloseyour health information to the extent necessaqr to!'lverta;seri.9.l,1f3Jbreatitas,yourhealth;,or~~tetypr .the healthor safetYof others. . ,. fc ~', {.;'~

John C. Stangl, D.D.S

':,-,.

, .." ...' .." - . '" ···(·~:V~,;;;<;,;:~~;,:~~[,:~),:t~"::JN'.,,<'National Security: We maydisclos~)9, m,ilitary ~,{Jth9mies;1~e,'he~Itf:(i~formatiOi'f of" ··ad ForeespersonneJ'uridercertain.circumstances.WemaYdlsclps~';to;autfi&rlied.:f~~el'~l[qfflpi. '.' '.. .... .' ·"·uited·.tOr·laWful·intelligencEi;co~~teririt~((jgence, and other na~i9~l;tlf~~g""li,~~~~i,!iti~~;~~~m~~:i"'k'" , ....: ..... .... itutiono~.I~wE)r:ltotcementofficial havlnglawfulcustodY'ofprotected"healthmformatlon'of,inmate or' . lent;u r certain circumstances.

~ppolntrne.~t R~!liJ~~~r~:yVe ~~y;,J~~fur·ai~ld~ey~ur;tl~a!{h~l~f~rffi~tibri;;t~;~;tovidgi{ojf'W\th;apPQintmetlt reminders(suchasvolcemallmessages;·p.ostt:ards, or leHerS):" ...., .'.' 0"':"'" ...." ".. .

.:~ =: ·r~;'->"- _.'. r ••• f -.'~;:~_,>.;;-..,:'; ., '~-'::-<~':>.' <,:-~;i"-:·s:7~:;;.~_~~--:'.·"··;·.... -:;-. ~., ..,,'-.... "~7...;~"~:>".:-:.::.../';"

PATIENTRIt3Ht~f;;;t . .'}.t:c:'.!<;::,c./,.; .:'}i. '.:;: iT·>';,"':._ •. ;.<

Access: You haveth'er-i9~t.10.loOk atorge.tcopie~()f·.yo~ffle1:llth.infolTll~,tion, with:Umitedexgeptions.¥()Urriay requestthst'l!eprovidElc()pies \haf()rmatQthert",~n;p'fldt'o'c6pie~;·:W~:iWiU'1U"s-ai;thefontlat. you. request unless we cannotpracticably do so. (You must make iil'eqIiEfgf'ln"w~ting: too~taiti acc~SScf()'your'healtlii;iFlfoimation.You-may obtaina form to request access by using the conracfinformiiJi6rfliste-d allhe end of this Notice. We; ~i!lc~~[g~ ,Y9u ar.e.asonabl~\co~t~bas,e.d fee to.r eX(J'er.l~essu.?~ a$p.oRie~~~d.s,taff t,iI!lElo"Y6umay ~ISo requ~s~ acc~¥ byrs-eriBing usa I~tt~rto the ;,addre$S :Ci~the end. of, this Ndtic.e. Jf,Y6lJ;;f%iti~stc9.~i~S; 'We,wiUj~hat.ge'yOti$s.9:0'f~r: eac~~F~ge,$_._.._'_._.per h~urfoq>taff timeto Iqc,at~and,coRy~,}lQurh:e~lt~~iiif(ir:!flatio~i a:ndp'()s~age:1fyou watirth~c'op,ie$~mail~dto you, If you request an alternative form~t,we: will>cRa"Qti'~cQst;~ase~.fe:E!Jor .pr9vi~i6~YdiJrJJ~al{h0i~(ortnaUp~'jfnhatfOlmat.lfyou prefer, we wiUprepare a summary or aneX~I~fu"M'ii:My6ti'~' he·althinfbrm~tid~';(6r~'. f.~e,b6Mtad:q$,b§ihgthe'informa'ti~n,listed;at theFer.lcj'9fthis.N0ticef.or·El'full~explanatjpn.:Qf:'gtllr4~~l>truptl;lre.)~,,·}.':··.·:t,':;,,-c;,Ji.',,." '.-, . ,,!~:-.. '.. .:,;,. ~/ ../.:s.';: ..: :~',>'~r~;~:-:;~~~.,:j•.~:,.)\,--.:~~... t;~'~·.'::,,~-;,~:"i'· . - .-,:./.

'Di'$'cIQsUl'e;,Accounting:You havethe;.riglifto":r~ceive,:a;'lists6f :i~stctI'i6~s'inMhith, we or •.QunbusimeS$asspciatesdls:<::los'ediyoiJrhe·?lth-inform8.tion·forptrrp'C5sesi'oftler,}t[ian"tteatiflegtf:paYnieht,'healthcareo~etation's'and:;ceitaircofh~r:'activities, forthe last 6 years, but not before April 14; 200S;.Ifyou,request;tnis a6countiligrnc;jre'tharf.·oncein 'a'42-'rtlOnth

'pe,nqd, we may char,geyou:ar~asonable;rc~st-based Jee.,for rE:t$P9nding10 these addjtional requests,., -'. - l _ .? . . .;, ',.,".~ ... -. -', _.' _. ..~_.., .';. " '

i<~:,-::, . .' _ -.,' ,-:. '<;,;',::~.~;,_:~~;}:,~:'.<',';,\ ,·>{'.,;_<::.~_,:,:,~?:·(::/"":i",:T'<:;}'i: .:,::':','~;::' ,<--'::':_.-"", :'-:, :;-' ',' -":~,;~~(;'. ,': f\.,o,·-,,,: ,~, ,,',/',',":,i,:":, .«. '.;

Restrlcti.on:. You. have the right torequesrtbat'Neplace 'l:idqitioru~rrestiibti(mS()n our use or di~¢losureof Your healthinf6rma:tion, We are not required to agree to theseadditi6naJrestfig:ti6n.S,;l;tutif vie dO,.,We,WiU.<;I,bidebyoUta:gr~erner.lt(el(q~Rtj~!iIJ~m~rgenc'Y)~ .... '., . .'0>' ...."J~':»':;'::::~::/'__~;_:;;:~,.',•. :>iJ'::';;;':"l'o;'~;~~':\~'_:,';"!i:;~'~,:C:','.Alter:na~lve1'Gommunicatioh: Youhave-the righttoti,e~(1lyesUhat:,w.~ I;:OrnmI;lQicate~ith.you .ab6u~ YQ",rf,h~althlnfCi1I'iTfatlonbyaltemative rneansor to-altemative locatiOns. (You must-make your request.in Writing.)Your requ~~t;nll!stspecify, alternative rneansor.IQCation,a~dprovide satisfabtoryexpla~ation how payments will be haocUed·under the-aJ~:ernativeme~h'sc)rlocationy6i:i request'- .... ...•. . ". i.,.

.::.",' :: ..'";,: _. • ,'_ .' "::/ :;, .~' _. _.-:).\r: >";(_~.:'.:'~: .' ,_ _ _ . ~'.. ;,J~' ~ _'~':: ....

4meodl'l1elit: You have me right to requestitha,twe~-ai.ner:td¥surbeal.~h,JJ;lformat!on~ (Y0'-:lrreq\J~,~tJllU~tpe,Jl11tllVr:itilig,'a'ndit;mustexplaibwhy the,informationshould,be,am!'iRdEld;),Wemaydeny,yourrequest tI,nder c:ertaincircurnstsnces.

-. -. • - -'. -. -. . . <- -'.- -. "". •

Ele~tronicNotice~ltyou receive this.Notice on ourWebSiteO;by'ei~ctronic mail"(e-ltiai.),. you 'are,:g~~itled t~'r~~eivethi~ Notiee in .writtenform. . . . . C,':' .' ,. . . ....., .' 'c:.'" .' ':< .

- .. :".; • ;./~::'~';; ;;....··,r•. ,-;',i.

././

(}4~$t:ION~4~Ei.¢,OMPLAI~TS.-< ... '" i ....".:» ' '.' •.•..••.• , •• , •..•• ; •.• ',,,, •..•.•••..•.. ;;" •..••.•...•.•. , .. ".,:, •..•. ,.' . '.' •• :".,.

If yOu want mote information' about our privacy ,ptact[~~s ;o{fia-.ie:questib~~::ol' conc~'rn~; P!~~~~'ctmtae:t!iis,""- .~. • • .• _ --.' '- ,.....- . ': .. -:'. '- ,', - .~' -r:,' . -' '- _. . ' .." . - :;. '.".';,'_ .": • ..f

'lFyou Sl'e,:eohcemed:thaf.w9 may have-violated your Priv.(lpy:,right~;.or, you disagre'ewitha.,decisien we .made.about~'cc~$~Hoyouro'ealth inforrriatidn or inr~spoAse'toa'feqU9'st,you madeto:arii·end.dr/r~striGtthe~useor. diSclol>,ure of -:

. yourh~al{h rn(6ifriati~h'6r t6'hciye:liJs •.C6mmuni~tewithV()l:I;bY';altem~tive"mea~s;,ot'at'-altem~tiveYIQG'atiorfs~ you maycO~P\~iXlto;(uS.;H~rO~~\~~:Btin~acti~fortJ;l~ti.o?.I,i~t~~i,~.th~.~p~.. :" . e. Y9~,~!.~0~ay,~~bmi~:,a,~~~~~ If~.rpP.!~!~Lt.0tl;le l;J.S>.dD,ePM.rnet;lt:(jfHealth~nd:Hl:J.l!ilar.lS~: . .~Jt. '....I;i!headdress toJ,le:y,()qI9,ornpl~IIl~.\Vlththe'U.S, Depad!iP~!JtQfl;ie~lthang:J:luQ)a!1,~~'~~w~oJ1reql;l: , '. Y , " • • I· '0 ",.:::>" ...We $liPPort:,;~'~r ri~hMothepnyaCY1drcy~u~'ih~~~~i~i6~ation: We-;WiU,not;etalifite in any wayjf ¥6uchOds,~'t~ iil~ a '.cOm'jlllainlfwith us or' with .theV ..~. 'bepartrtlent±6f";Healtfrahc:l, Human'Services.· ..,.,

Contact Officer:' JOhn c. siangl;liD~S.

Telephone: 7, ,7$3"682-68.85

.: e.

Buffalo Family Dentistry-' I()& ,Ce/J7L£v. Dr. Buffalo MN 55313

" ,(763) 682-6885 Fax: (763) 682-4534

ACKNOWLEDGEMENT OF RECEIPT OFNOTICE OF PRIVACY PRACTICES

* You May Refuse to Sign This Acknowledgement *

I, --, have received a copy of thisoffice's Notice of Privacy Practices.

Please Print Name

Signature

Date

For Office Use Only

We attempted to obtain written acknowledgement of our Notice of Privacy Practices, butacknowledgement could not be obtained because:

o Individual refused to sign

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John C. Stangl, D.D.S