Privacy Policy

Evolution Endodontics and Periodontics
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.

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 02/16/2026, 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.

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.

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HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

We may use and disclose your health information for different purposes, including
treatment, payment, and health care operations. For each of these categories, we have
provided a description and an example. Some information, such as HIV-related
information, genetic information, alcohol and/or substance abuse records, and mental
health records may be entitled to special confidentiality protections under applicable state
or federal law. We will abide by these special protections as they pertain to applicable
cases involving these types of records.

Treatment. We may use and disclose your health information for your treatment. For
example, 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
the treatment and services you receive from us or another entity involved with your care.
Payment activities include billing, collections, claims management, and determinations of
eligibility and coverage to obtain payment from you, an insurance company, or another
third party. For example, we may send claims to your dental health plan containing certain
health information.

Healthcare Operations. We may use and disclose your health information in connection
with our healthcare operations. For example, healthcare operations include quality
assessment and improvement activities, conducting training programs, and licensing
activities.

Individuals Involved in Your Care or Payment for Your Care. We may disclose your health
information to your family or friends or any other individual identified by you when they are
involved in your care or in the payment for your care. Additionally, we may disclose
information about you to a patient representative. If a person has the authority by law to
make health care decisions for you, we will treat that patient representative the same way
we would treat you with respect to your health information.

Disaster Relief. We may use or disclose your health information to assist in disaster relief
efforts.

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

Public Health Activities. We may disclose your health information for public health
activities, including disclosures to:

o Prevent or control disease, injury or disability;

o Report child abuse or neglect;

o Report reactions to medications or problems with products or devices;

o Notify a person of a recall, repair, or replacement of products or devices;

o Notify a person who may have been exposed to a disease or condition; or

o Notify the appropriate government authority if we believe a patient has been the
victim of abuse, neglect, or domestic violence.

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 the protected health information of an inmate or patient.

Secretary of HHS. We will disclose your health information to the Secretary of the U.S.
Department of Health and Human Services when required to investigate or determine
compliance with HIPAA.

Worker’s Compensation. We may disclose your PHI to the extent authorized by and to the
extent necessary to comply with laws relating to worker’s compensation or other similar
programs established by law.

Law Enforcement. We may disclose your PHI for law enforcement purposes as permitted
by HIPAA, as required by law, or in response to a subpoena or court order.

Health Oversight Activities. We may disclose your PHI to an oversight agency for activities
authorized by law. These oversight activities include audits, investigations, inspections,
and credentialing, as necessary for licensure and for the government to monitor the health
care system, government programs, and compliance with civil rights laws.

Judicial and Administrative Proceedings. If you are involved in a lawsuit or a dispute, we
may disclose your PHI in response to a court or administrative order. We may also disclose
health information about you in response to a subpoena, discovery request, or other lawful
process instituted by someone else involved in the dispute, but only if efforts have been
made, either by the requesting party or us, to tell you about the request or to obtain an
order protecting the information requested.

Research. We may disclose your PHI to researchers when their research has been
approved by an institutional review board or privacy board that has reviewed the research
proposal and established protocols to ensure the privacy of your information.

Coroners, Medical Examiners, and Funeral Directors. We may release your PHI to a
coroner or medical examiner. This may be necessary, for example, to identify a deceased
person or determine the cause of death. We may also disclose PHI to funeral directors
consistent with applicable law to enable them to carry out their duties.

Fundraising. We may contact you to provide you with information about our sponsored
activities, including fundraising programs, as permitted by applicable law. If you do not
wish to receive such information from us, you may opt out of receiving the communications.
We will not use or disclose Part 2 records for fundraising purposes unless you are given
a clear opportunity to opt out.

Other Uses and Disclosures of PHI

Your authorization is required, with a few exceptions, for disclosure of psychotherapy
notes, use or disclosure of PHI for marketing, and for the sale of PHI. We will also obtain
your written authorization before using or disclosing your PHI for purposes other than those
provided for in this Notice (or as otherwise permitted or required by law). You may revoke
an authorization in writing at any time. Upon receipt of the written revocation, we will stop
using or disclosing your PHI, except to the extent that we have already taken action in
reliance on the authorization.

SUBSTANCE USE DISORDER RECORDS (42 CFR PART 2)
Some health information about you may be protected by additional federal confidentiality
rules for substance use disorder records under 42 CFR Part 2 (“Part 2 records”), in addition
to HIPAA. If we receive or maintain any Part 2 records about you, we will handle those
records as follows: Use and Disclosure with General Consent: If we receive Part 2 records
through a general consent you provided to a Part 2 Program, we may use and disclose those
records for treatment, payment, and health care operations as permitted by federal law.
Use and Disclosure with Specific Consent: If we receive Part 2 records under a specific
consent, we will only use or disclose those records as expressly authorized by your
consent. Legal Protections: We will not use or disclose your Part 2 records, or testify about
them, in any civil, criminal, administrative, or legislative proceeding against you unless: You
provide written consent; or a court orders the disclosure after you have had notice and an
opportunity to object.

Your Health Information Rights

Access. You have the right to look at or get copies of your health information, with limited
exceptions. You must make the request in writing. You may obtain a form to request access
by using the contact information listed at the end of this Notice. You may also request
access by sending us a letter to the address at the end of this Notice. If you request
information that we maintain on paper, we may provide photocopies. If you request
information that we maintain electronically, you have the right to an electronic copy. We
will use the form and format you request if readily producible. We will charge you a
reasonable cost-based fee for the cost of supplies and labor of copying, and for postage if
you want copies mailed to you. Contact us using the information listed at the end of this
Notice for an explanation of our fee structure.

If you are denied a request for access, you have the right to have the denial reviewed in
accordance with the requirements of applicable law.

Disclosure Accounting. With the exception of certain disclosures, you have the right to
receive an accounting of disclosures of your health information in accordance with
applicable laws and regulations. To request an accounting of disclosures of your health
information, you must submit your request in writing to the Privacy Official. 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 the additional requests.

Right to Request a Restriction. You have the right to request additional restrictions on our
use or disclosure of your PHI by submitting a written request to the Privacy Official. Your
written request must include (1) what information you want to limit, (2) whether you want to
limit our use, disclosure or both, and (3) to whom you want the limits to apply. We are not
required to agree to your request except in the case where the disclosure is to a health plan
for purposes of carrying out payment or health care operations, and the information
pertains solely to a health care item or service for which you, or a person on your behalf
(other than the health plan), has paid our practice in full.

Alternative Communication. You have the right to request that we communicate with you
about your health information by alternative means or at alternative locations. You must
make your request in writing. Your request must specify the alternative means or location,
and provide satisfactory explanation of how payments will be handled under the alternative
means or location you request. We will accommodate all reasonable requests. However, if
we are unable to contact you using the ways or locations you have requested we may
contact you using the information we have.

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. If we agree to your request, we
will amend your record(s) and notify you of such. If we deny your request for an
amendment, we will provide you with a written explanation of why we denied it and explain
your rights.

Right to Notification of a Breach. You will receive notifications of breaches of your
unsecured protected health information as required by law.

Electronic Notice. You may receive a paper copy of this Notice upon request, even if you
have agreed to receive this Notice electronically on our Web site or by electronic mail (e-
mail).

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, or if
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.

Our Privacy Official:
Cari Gleason Telephone: 720-221-7774 Fax: 720-221-4594
Address: 7753 Maleta Ln, Suite 201, Castle Rock, CO 80108
E-mail: businessmanager@evolutionendo.com