Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL AND DENTAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Effective Date: September 29, 2026

This Notice of Privacy Practices ("Notice") is provided as required by the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations ("HIPAA"). It describes how Ashby Park Pediatric Dentistry may use and disclose your Protected Health Information ("PHI") to carry out treatment, payment, or health care operations, and for other purposes permitted or required by law. It also describes your rights regarding your PHI.

1. Our Commitment to Your Privacy

We are required by law to maintain the privacy of your PHI, to provide you with this Notice describing our legal duties and privacy practices, and to abide by the terms of the Notice currently in effect. PHI is information about you, including demographic information, that may identify you and that relates to your past, present, or future physical or oral health condition and related health care services.

2. How We May Use and Disclose Your PHI

A. For Treatment

We may use and disclose your PHI to provide, coordinate, or manage your dental care, such as sharing information with a dental laboratory, a specialist to whom we refer you, or another treating provider.

B. For Payment

We may use and disclose your PHI to bill and collect payment for services, including submitting claims to your dental insurance carrier, verifying coverage, and processing payments through our billing partners.

C. For Health Care Operations

We may use and disclose your PHI for activities necessary to run our practice, such as quality assessment, staff training, licensing, and business planning.

D. Appointment Reminders and Treatment Alternatives

We may contact you by phone, text message, email, or mail to remind you of appointments or to tell you about treatment alternatives or other health-related services that may be of interest to you.

E. As Required or Permitted by Law

• When required by federal, state, or local law (e.g., public health reporting, abuse/neglect reporting);
• For judicial or administrative proceedings, in response to a court order or valid subpoena;
• For law enforcement purposes, under limited circumstances defined by law;
• To avert a serious threat to health or safety;
• For workers' compensation, as authorized by applicable law.

F. Other Uses and Disclosures

Any use or disclosure of your PHI not described in this Notice, including uses or disclosures of psychotherapy notes (if applicable) or for marketing purposes unrelated to your treatment, and any sale of PHI, will be made only with your written authorization. You may revoke that authorization in writing at any time, except to the extent we have already relied on it.

3. Your Rights Regarding Your PHI

• Right to Access — You may inspect and obtain a copy of your dental record, with limited exceptions. We may charge a reasonable, cost-based fee.
• Right to Request Amendment — You may ask us to amend your PHI if you believe it is incorrect or incomplete. We may deny the request in certain circumstances, and will explain why in writing.
• Right to an Accounting of Disclosures — You may request a list of certain disclosures we have made of your PHI in the six years prior to your request.
• Right to Request Restrictions — You may ask us to restrict how we use or disclose your PHI for treatment, payment, or operations. We are not required to agree, except where you paid out-of-pocket in full for a specific item or service and ask that we not disclose it to your health plan.
• Right to Request Confidential Communications — You may ask us to communicate with you in a certain way or at a certain location (e.g., only by mail to a specific address).
• Right to a Paper Copy — You may request a paper copy of this Notice at any time, even if you agreed to receive it electronically.
• Right to Notification of a Breach — We will notify you if there is a breach of your unsecured PHI, as required by law.

To exercise any of these rights, submit a written request to our Privacy Officer using the contact information in Section 6.

4. Our Responsibilities

• We are required by law to maintain the privacy and security of your PHI.
• 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; you may change your mind at any time by informing us in writing.

5. Changes to This Notice

We reserve the right to change this Notice at any time and to make the revised Notice effective for PHI we already have as well as PHI we receive in the future. The current Notice will be posted in our office and on our website, and you may request a copy at any time.

6. Complaints

If you believe your privacy rights have been violated, you may file a complaint with us or with the U.S. Department of Health and Human Services, Office for Civil Rights at https://www.hhs.gov/hipaa/filing-a-complaint. You will not be penalized or retaliated against for filing a complaint.

To file a complaint with the Practice, contact our Privacy Officer:

• Ashby Park Pediatric Dentistry — Greenville, SC

Acknowledgment of Receipt

Patients are typically asked to sign a separate, one-page Acknowledgment of Receipt of this Notice at their first visit, which is retained in the patient's chart. A good-faith effort to obtain this acknowledgment (and documentation of that effort if a patient declines to sign) is a HIPAA requirement, separate from posting or distributing this Notice.