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.

Joshua M Ignatowicz DMD & Associates is committed to protecting your privacy, and we have adopted privacy practices to protect the information we gather from you. We understand that health/dental information about you and your health is personal. We are committed to protecting health/dental information about you. The Notice of Privacy Practices (“Notice”) describes the privacy practices of Joshua M Ignatowicz DMD & Associates and will tell you about the ways in which we may use and disclose health/dental information about you and how you can get access to this information. We also describe your rights and certain obligations we have regarding the use and disclosure of health/dental information with respect to your “Protected Health Information” (as defined by the Health Insurance Portability and Accountability Act of 1996 and its regulations, as amended from time to time).

We typically use or share your health information in the following ways:

• Treat you. We can use your health information and share it with other professionals who are treating you. An example of this would

be a doctor treating you for an injury asks another doctor about your overall health condition.

• Bill for your services. We can use and share your health information to bill and get payment from health plans or other entities. An

example of this would be sending a bill for your visit to your insurance company for payment.

• Run our office. We can use and share your health information to run our practice, improve your care, and contact you when

necessary. An example would be an internal quality assessment review. This may include quality assessment, staff training,

accreditation, licensing activities, and business planning and development.

How else can we use or share your health information. We are allowed or required to share your information in other ways – usually to contribute to the public good, such as public health and research. We must meet many conditions in the law before we can share your information for these purposes. For more information, see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

• Help with public health and safety issues. We can share health information for certain situations, such as preventing disease,

reporting suspected abuse, neglect, or domestic violence, preventing/reducing a serious threat to anyone’s health or safety.

• Comply with law. We will share information about you if state or federal law requires it, including with the U.S. Department of Health

and Human Services if it wants to see that we are complying with federal privacy law.

• Do Research. We can use and share information for health research.

• Family and Friends: We may disclose your health information to a family member or friend who is involved in your medical care or to

someone who helps pay for your care. We may also use or disclose your health information to notify (or assist in notifying) a family

member, legally authorized representative, or other person responsible for your care of your location, general condition, or death. If

you are a minor, we may release your health information to your parents or legal guardians when we are permitted or required to do

so under federal and applicable state law.

• Organ and tissue donation requests. We can share information about you to organ procurement organizations.

• Medical examiner or funeral director. We can share information with a coroner, medical examiner, or funeral director when an

individual dies.

• Worker compensation, law enforcement requests, and other governmental requests. We can share health information for worker

compensation claims, law enforcement purposes, with health oversight agencies for activities allowed by law, and other specialized

government functions (e.g., military and national security).

• Lawsuits and legal actions. We can share health information in response to court or administrative order, or in response to a

subpoena.

• Reproductive health care information. Federal rules may limit when we may use or disclose protected health information related to

lawful reproductive health care for certain non-health-care purposes (such as certain investigations, law enforcement requests,

oversight activities, or legal proceedings). When required, we may need to obtain a signed attestation from the requester before

making certain disclosures.

When it comes to your health information, you have certain rights under federal and applicable state law:

• Get an electronic or paper copy of your health/dental information. You can ask to see or get a copy of your health information that

we maintain in a designated record set. We will provide a copy or a summary, as you request, within 30 days (or we will provide you

a written explanation if we need more time as allowed by law). If we maintain your information electronically, you may request an

electronic copy. You may also request that we send a copy to a person or organization you choose (your request must be in writing,

signed, and clearly identify where to send it). We may charge a reasonable, cost-based fee as allowed by law.

• Ask us to correct your health/dental record. You can ask us to correct health information about you that you think is incomplete or

incorrect. We may say “no” to your request, but we will tell you why in writing within 60 days.

• Confidential communications. You can ask us to contact you in a specific way (for instance home or office phone) or to send mail to

a different address for items such as appointment reminders. We will say yes to all reasonable requests.

• Limits on what we use and share. You can ask us NOT to share certain health information for treatment, payment, or operations. We are not required to agree to your request, and if it affects your care, we may say no. If you pay for a service or item in full out-of-pocket, you can ask us not to share information about that service or item with your health plan for payment or our operations. We will agree unless a law requires us to share that information.

• Accounting of disclosures. You can ask for a list (accounting) of the times we have shared your health information for the prior six

years. We will include all disclosures, except those about treatment, payment, and operations. We will provide one accounting for

free, but may charge a reasonable, cost-based fee if you ask for another within 12 months.

• Substance Use Disorder (SUD) Records (42 CFR Part 2) (if applicable). If we receive or maintain records that are subject to 42

CFR Part 2, those records may have additional federal protections and limitations on use and disclosure. We will follow applicable

Part 2 requirements when they apply, including any requirements related to patient consent and restrictions on redisclosure.

• Fundraising. We do not use your information for fundraising communications.

• Privacy Notice. You can ask and receive a paper copy of this notice at any time.

• Complaint. You can file a complaint if you feel we have violated your rights, with the office at the address below, or you with the

Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Ave, SW, Room 509F

HHH Bldg., Washington, D.C. 20201, calling 1-877-696-6775, or by visiting: www.hhs.gov/ocr/privacy/hipaa/complaints/. We will

not retaliate against you for filing a complaint.

Uses and disclosures that require your written authorization: We will not use or disclose your protected health information without your written

authorization for the following purposes (except as otherwise permitted by law):

• Marketing.

• Sale of protected health information.

• Most uses and disclosures of psychotherapy notes (if applicable).

You may revoke your authorization in writing at any time unless we have already acted based on it.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

State Law

We will not use or share your information if state law prohibits it. Some states have laws that are stricter than the federal privacy regulations, such as laws protecting HIV/AIDS information or mental health information. If a state law applies to us and is stricter or places limits on the ways we can use or share your health information, we will follow the state law. If you would like to know more about any applicable state laws, please ask our Privacy Officer. Some types of information (for example, certain mental health, HIV/AIDS, genetic, or substance use disorder information) may have additional protections under applicable law.

We are required by law to maintain the privacy and security of your protected health information. We will notify you following applicable legal

requirements if a breach occurs that may have compromised the privacy or security of your information. This notice is effective as of January 1, 2026. We reserve the right to change this Notice, and the changes will apply to all protected health information we maintain. We will make the updated Notice available upon request, in our office, and on our website (if applicable)

If you have any questions or want more information about this notice or how to exercise your health information rights, you may contact our Privacy Officer, [Jan Krahenbuhl], by mail at: [1070 W Horizon Ridge Pkwy, Suite 110 Henderson, NV 89012] or telephone at [702-473-5100]. You have the right to exercise any of the actions in the above document, and the Privacy Officer will guide you through the process.

 I request that information not be discussed with family or friends except as permitted by law (for example, in emergencies).

 I authorize information about treatment or appointments to be discussed with the following person(s):

__________________________________________________________

__________________________________________________________

I have read and understand the above information.

__________________________________________________________.    ______________________________

First Name                                      Last Name                               Birthdate

__________________________________________________________    ______________________________

Patient Signature (or Authorized Representative)                   Date

FOR OFFICE USE ONLY

The following patient/authorized representative ______________________________

 Refused to sign the Notice of Privacy Practices because __________________________________________

 Was unable to sign the Notice of Privacy Practices because _______________________________________