1551 Bishop Street Suite D-420 San Luis Obispo CA 93401 www.Slodentalpractice.com

805 547 7010

Welcome to our office

With over seventeen years experience in Dentistry, Disbel Mansilla, DDS is uniquely qualified to restore smiles in a conservative and as painless a way possible. She is dedicated to restoring her patients to an optimal degree of dental health using the latest technological advances, and the best in care. This welcome packet is designed to prepare you for your first visit as a patient of SLO Dental.

Please fill out all forms completely and as thorough as possible. It is important to us to have the

most complete, and up to date information so that we may treat you effectively and efficiently.

We ask that you also take the time to fill out the short pre-visit survey included; this is essential

to our continual process of practicing excellent customer service.

We welcome the opportunity to become your family dentist; our goal is to make you smile!

Patient Information (CONFIDENTIAL) Date _______________

Name (First, Last): _______________________________________________ Birthday: ____________________ SSN: ________________________ Address: ______________________________________________ City: _____________________ State: ___________ Zip Code: _________________ Home Phone: _______________________________ Cell Phone: _____________________________ Other: _________________________________ E-mail address: ________________________________________________________________________ Check Appropriate Box: Minor Single Married Divorced Widowed Separated If Student, Name of School/College: _____________________________ City: __________ State: ________ Full time Part Time Patient or Parent/Guardian’s Employer: ________________________________________ Work Phone: _____________________________ Business Address: _____________________________________________________ City: _______________ State: ____ Zip Code: ____________ Spouse or Parent/Guardian’s Name _________________________________ Employer: ____________ Work Phone: ________________ Person to contact in case of emergency: ______________________________________________________ Phone: _______________________ How did you �ind about us? Friend/Family

Responsible Party Name of person responsible for this account: ________________________________ _ Relationship to Patient: __________________ Address: ________________________________ City: _______________ State:______ Zip Code: _________ Phone: _________________________ E-mail: ______________________________________________________________ Cell Phone: _______________________________________________ Driver’s License #: ______________________________ Birthday: ___________________ Financial Institution: _______________________ Employer: ________________________________________ Work Phone: __________________________ SSN: _______________________________ Is this person currently a patient in our of�ice? Yes No Insurance Information Name of Insured: __________________________________________ Relationship to Patient: _________________________________________ Birthday: _________________ SSN: ____________________ Employer: ________________ Date Employed: _____________________________ Address of Employer: ___________________ City: _______________ State: ______ Zip Code: _________ Phone: ______________________ Insurance Company: __________________________________ Group#_______________ Policy/ID #: __________________________________ Ins. Co. Address: _______________________________________ City: _____________________ State: __________ Zip Code: ________________ How much is your deductible? ______________ Max annual bene�it _________________ How much have you used? ___________

Do you have additional insurance? Yes No If yes, complete the following: Name of Insured: __________________________________________ Relationship to Patient: _________________________________________ Birthday: _________________ SSN: ____________________ Employer: ________________ Date Employed: _____________________________ Address of Employer: ___________________ City: _______________ State: ______ Zip Code: _________ Phone: ______________________ Insurance Company: __________________________________ Group#_______________ Policy/ID #: __________________________________ Ins. Co. Address: _______________________________________ City: _____________________ State: __________ Zip Code: ________________ How much is your deductible? ______________ Max annual bene�it _________________ How much have you used?__________

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Patient Medical History Physician __________________________________________________ Date of last exam: _______________________ YES NO 1. Are you under medical treatment now? ………………………………………………………………………… 2.Have you ever been hospitalized for any surgical operation or serious illness within

the last 5 years? If yes, please explain ……………………………………………………………………………… ______________________________________________________________________________________________________

3.Are you taking any medication(s) including non-prescription medicine?......................................... If yes, what medication(s) are you taking? ____________________________________________________________________________________

4.Have you ever taken Fen-Phen/Redux?............................................................................................................. 5.Have you ever taken Fosamax, Boniva, Actonel or any cancer medications

containing bisphonates? ………………………………………………………………………………………………….. 6.Have you taken Viagra, Revati, Cialis or Levitra in the last 24 hours?................................................. 7.Do you use tobacco?............................................................................................................................. ..................... 8.Do you use controlled substances?..................................................................................................................... 9.Are you wearing contact lenses?.......................................................................................................................... 10. Do you have a persistent cough or throat clearing not associated with a known

illness (lasting more than 3 weeks)?............................................................................................................. 11. Women Only:

a) Are you pregnant or think you may be pregnant?........................................................... b) Are you nursing?............................................................................................................................. c) Are you taking oral contraceptives?......................................................................................

Are you allergic to or have you had any reactions to the following? (please check the appropriate box)12. Local anesthetics (e.g. Novocain) Penicillin or any other antibiotics Sulfa Drugs Barbiturates Sedatives Iodine Aspirin Any Metals (e.g. nickel, mercury, etc.) Latex Rubber Other (please list)____________________________________________________________________________

13. Do you have or have you had any of the following? High Blood Pressure Heart attack Rheumatic Fever Swollen Ankles Fainting / Seizures Asthma Low Blood Pressure Epilepsy / Convulsions Leukemia Diabetes Kidney Diseases AIDS or HIV Infection Thyroid Problem Heart Disease Cardiac Pacemaker Heart Murmur Angina Frequently Tired Anemia Emphysema Cancer Arthritis Join Replacement or Implant Hepatitis/Jaundice Sexually Transmitted Disease Stomach Troubles/ Ulcers Chest Pains Easily Winded Stroke Hay Fever/Allergies Tuberculosis Radiation Therapy Glaucoma Recent Weight Loss Liver Disease Heart Trouble Respiratory Problems Mitral Valve Prolapse Other _________________________

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Patient Dental History Name of previous dentist and location: __________________________________________________________________________________ Date of last exam: _________________________________________ YES NO

1. Do your gums bleed while brushing or �lossing?........................................................................................... 2. Are you teeth sensitive to hot or cold liquids/foods?.................................................................................. 3. Are you teeth sensitive to sweet or sour liquids/foods?............................................................................ 4. Do you feel pain to any of your teeth?................................................................................................................ 5. Do you have any sores or lumps in or near your mouth?......................................................................... 6. Have you had any head, neck or jaw injuries?................................................................................................ 7. Have you ever experienced any of the following problems in your jaw?

Clicking…………………………………………………………………………………………………………………………… Pain (joint, ear, side of face)……………………………………………………………………………………………... Dif�iculty in opening or closing…………………………………………………………………………………………. Dif�iculty in chewing…………………………………………………………………………………………………………

8. Do you have frequent headaches?........................................................................................................................ 9. Do you clench or grind your teeth?...................................................................................................................... 10. Do you bite your lips or cheeks frequently?.................................................................................................... 11. Have you ever had any dif�icult extractions in the past?........................................................................... 12. Have you ever had any prolonged bleeding following extractions?..................................................... 13. Have you had any orthodontic treatment?...................................................................................................... 14. Do you wear dentures or partials?......................................................................................................................

If yes, date of placement __________________________________________________ 15. Have you ever received oral hygiene instructions regarding the care of your teeth and gums? 16. Do you like your smile?.............................................................................................................................................

Authorization and Release I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payers and/or health practitioners. I authorized and request my insurance company to pay directly to the dentist or dental group insurance bene�its otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependants. _________________________________________________________ ________________________________ Signature of patient (or parent/guardian if minor) Date Doctor’s Comments: __________________________________________________________________________________________________________

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Signature__________________________________________ Date ___________________________

Care and Payment Policy

Dental treatment is an excellent investment in an individual’s medical and psychological care. We realize every patient’s financial situation is different. For this reason, we have created a variety of payment options to help you receive the dental care you need and deserve. Please do not hesitate to ask any questions; we are always available to assist you in any way we can.

Optional Payment Terms:

Insurance: We are providers for many dental plans, and are happy to bill your plan as a courtesy to you. If your Insurance company does not cover their expected portion within 60 days, you will be required to pay the remaining balance.

Full Cash Payment Discount: We offer a 5% accounting courtesy for all treatment that is paid in full at the time of service.

Major Service Payment Option: We offer a two payment option for crown, bridge, and denture treatment. We ask that you pay one half of your co-payment at the first appointment, and the remaining is due at the time of delivery or seat date appointment.

Credit Card Payment Option: We allow a credit card payment option consisting of 2 equal payments. One half of the total payment is due at the time of first appointment, and the remainder is due 30 days later. A signed agreement will be kept on file, and your card will be charged on the date easiest for you.

Care Credit

Payment is expected at the time of service. We accept cash, check, debit, and all major credit cards. Please call if you are unable to make an appointment or need to reschedule; missed appointments without 24 hours notice are subject to a cancellation fee of $25 per 30 minutes reserved for you.

: We are providers of Care Credit, a flexible payment program with little or no interest. With Care Credit you may begin treatment immediately, finance up to 100% of the treatment with a low monthly payment, and choose between several flexible options. Please ask our Office Manager for an application and to answer any questions you may have.

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Patient or Guarantor Date

Patient Consent to Treatment

In reading and signing this consent form it is understood that English is the language that I understand and use to communicate.

(Initials) __________

1. DRUGS, MEDICATIONS, AND ANESTHESIA: I understand that antibiotics, analgesics, and other medications may cause adverse reactions, some of which, and are not limited to, redness and swelling of tissue, pain, itching, vomiting, dizziness, cardiac arrest.

I understand that medications, drugs, and anesthetics may cause drowsiness and lack of coordination, which can be increased by alcohol or the use of drugs. I have been advised not to consume alcohol, nor operate any vehicle or hazardous device while taking medication and/or drugs, or until fully recovered from the effects (this includes a period of at least twenty four (24) hours after my release from surgery).

I understand that occasionally, upon injection of local anesthesia, I may have prolonged, persistent anesthesia, numbness, and/or irritation to the area of injection. I understand that if I select to utilize Nitrous Oxide, Atara, Chloryl Hydrate, Zanax, or any other sedative, possible risk include, but not the limited to, loss of consciousness, obstructive airway, anaphylactic shock, cardiac arrest. I understand that someone needs to drive me home from the dental of�ice after I have received sedation. I also understand that someone needs to watch me closely for period of 8 to 10 hours, following my dental appointment to observe for possible deleterious side effects, such as obstruction airway.

(Initials)__________ 2. HYGIENE AND PERIODONTICS (TISSUE AND BONES LOSS): I understand that long term success of a treatment and status of my oral condition depends on my efforts at proper oral hygiene (i.e. brushing and �lossing) and maintain regular recall visits.

(Initials)__________ • PERIODONTICS: I understand that I have a serious condition causing gum and bone in�lammation and/or loss,

and that it can lead to loss of my teeth and other complications. The various treatment plans have been explained to me, including gum surgery, replacement and/or extractions. I also understand that although these treatment plans have a high degree of success, they cannot be guaranteed. Occasionally, treated teeth may require extraction.

(Initials)__________ 3. REMOVAL OF TEETH: I understand that the purpose of the procedure/surgery is to treat and possibly correct my diseased oral tissues. The doctor has advised me that if this condition persists without treatment or surgery, my present oral condition will probably worsen in time. Potential risks include but are not limited to the following:

• Post-Operative discomfort: swelling, prolonged bleeding, tooth sensitivity to hot or cold, gum shrinkage

(possible exposing crown margins), tooth looseness, delayed healing (dry socket and/or infections). Requiring prescriptions or additional treatment; i.e. surgery.

• Injury to adjacent teeth, caps, or �illings requiring recommended crowns, replacement of �illings, or extractions. • Injury to other tissues not within the described surgical area. • Limitation of opening, stiffness of facial and/or neck muscles, change in bite, or temporomandibular joint

dif�iculty (jaw pain) possibly requiring physical therapy or surgery. • Residual root fragments or bone spicules left when complete removal would require extensive surgery or

needless surgical complications.

• Possible bone fracture which may require wiring or surgical treatment. • Opening of sinus ( a normal cavity situated above the upper teeth) requiring additional surgery. • Injury to the nerve under laying the teeth resulting in itching, numbness, or burning of the lip, chin, gums,

teeth, and/or tongue on the operated side. This may persist for several weeks, months, or in remote instance permanently.

(Initials)__________ I give my consent for the doctor to perform the treatment/procedure/surgery previously explained to me, or procedures in deemed necessary or advisable as necessary to complete planned operation. If any unforeseen condition should arise in the course of the operation, calling for doctor’s judgment or for procedures in addition to or different from those now contemplated. I request and authorize the doctor to do whatever(s) she/he may deem advisable including referral to another dentist or specialist. I also understand that the cost of the referral is my responsibility.

(Initials)__________ 4. FILLINGS: I have been advised of the need for �illings, either silver or composite (plastic). To replace tooth structure lost to decay. I understand that with the time the �illing will need to be replaced due to wearing of material. In cases where very little tooth structure remains, or existing tooth structure fractures off, I may need to received more extensive treatment such as root canal therapy, post and build up, and crowns which will have a separate charge. I understand that the silver amalgam restoration is an acceptable procedure according to the American Dental Association guidelines, and such treatment is used by SLO Dental Practice. The advantages and disadvantages of alternate materials have been explained to me.

(Initials)__________ 5. ENDODONTIC TREATMENT (ROOT CANAL THERAPY) The purpose and method of root canal therapy have been explained to me, as well as reasonable alternative treatments, and the consequences of non-treatment. I understand that following root canal therapy, my tooth will be brittle and must be protected against fracture by placement of crown (cap) over the tooth. I understand that the treatment risks include and are not limited to the following: • Post-operative discomfort, and/or swelling which may persist for a prolonged period of time. Medication will

be prescribed if deemed necessary by the doctor. • Injury to adjacent teeth, caps, or �illings requiring recommended crowns, replacement of �illings, or extractions. • Injury to other tissues not within the described surgical area. • Limitation of opening, stiffness of facial and/or neck muscles, change in bite, or temporomandibular joint

dif�iculty (jaw pain) possibly requiring physical therapy or surgery. • Infection. • Breakage of root canal instruments during treatment, which may in the judgment of the doctor be left in the

treated root canal or bone as part of the �illing material, or it may require surgical removal. • Perforation of the canal with instruments. This may require additional surgery, or result in premature tooth

loss or extraction. • Injury to the nerve under laying the teeth resulting in itching, numbness, or burning of the lip, chin, gums,

teeth, and/or tongue on the operated side. This may persist for several weeks, months, or in remote instance permanently.

If an “open and medicate” or pulpotomy procedure is performed, I understand that this is not permanent treatment, and I need to pay for it, and �inish �inal root canal therapy. If root canal treatment is not �inalized, I expose myself to infection and/or tooth loss.

If failure of root canal therapy occurs, the treatment may have to be redone; root-end surgery may be required, or the tooth may have to be extracted. (Initials)__________

6. CROWN AND BRDIGES: I understand that sometimes it is not possible to match the color of the natural teeth exactly with arti�icial teeth. I understand that at times, during the preparation of a tooth for a crown, pulp exposure may occur necessitating possible root canal therapy. I understand that like natural teeth, crowns and bridges need to be kept clean with proper oral hygiene and periodic cleanings; otherwise, decay may develop underneath and/or around the margins of the restoration, leading to further dental treatment.

(Initials)__________ 7. DENTURES-COMPLETE OR PARTIAL: The problem of wearing dentures has been explained to me including looseness, soreness and possible breakage and relining due to tissue change. Follow-up appointments are an integral part of maintenance and success of prosthetic appliance. Persistent sore spots should be immediately examined by the doctor. I further understand that surgical intervention (i.e. Tori [bone] removal, bone recon touring, or implants) may be needed for dentures to be properly �itted. I also understand that due to bone loss or other complication factors, I may never be able to wear dentures to my satisfaction.

(Initials)_________ 8. PEDODONTICS (CHILD DENTISTRY) I understand that the following procedures are routinely used at the SLO Dental Practice, as well as being accepted procedures in the dental profession: • POSITIVE REINFORCEMENT: rewarding the child who portrays desirable behavior, by use of compliments,

praise and pat or hug, and/or token objects or toys. • VOICE CONTROL: the attention of a disruptive child is gained by changing the tone or increasing the volume of

the doctor’s voice. • NITROUS OXIDE AND/OR ORAL SEDATION: Nitrous oxide is a mild gas that is mixed with oxygen and is used to

sedate a person. It is administered through a mask placed over the child’s nose. Oral sedations are medications administrated to help children to relax. With their use, the parent or guardian must understand that the child should not eat or drink for a period of four hours prior to the sedation appointment. The parent or guardian must be able to escort the child home after sedation procedure, and observe their behavior through the day.

I understand that with the use of an injection, used to numb the tooth are for dental procedures, the possibility exist that the child may have inadvertently bit their lip causing injury to occur. I understand the need o return to the of�ice for evaluation if swelling and/or pain in my child does not go away after suf�icient period of time. I understand the need to return to the of�ice within three months following nerve treatment of a “baby tooth” for evaluation and the possible need for extraction. (Initials)__________

I understand that no guarantee or assurance has been given that the proposed treatment will be curative and/or successful to my complete satisfaction. I agree to care, realizing that any lack of same could result in less than optimal results. i certify that i have had an opportunity to read and fully understand the terms and words within the above, including the previous two pages , and consent to the operation and explanation referred to or made. I have been encouraged to ask questions and have had them answered to my satisfaction. I understand that SLO Dental Practice provides services without discrimination based on race, religion, color, national origin, sex, sexual orientation, physical or mental disability, age, or marital status. i understand that SLO Dental Practice protects the privacy of each of its patients. Signature:______________________________________________ Relationship to Patient: __________________________________________ Doctor:_________________________________________________ Witness:_____________________________________ Date: ________________

The following document is the Dental Board of California's Dental Materials Fact Sheet. The Department of Consumer Affairs has no position with respect to the language of this Dental Material Fact Sheet; and its linkage to the DCA website does not constitute an endorsement of the content of this document.

The Dental Board of California Dental Materials Fact Sheet Adopted by the Board on October 17, 2001

As required by Chapter 801, Statutes of 1992, the Dental Board of California has prepared this fact sheet to summarize information on the most frequently used restorative dental materials. Information on this fact sheet is intended to encourage discussion between the patient and dentist regarding the selection of dental materials best suited for the patient's dental needs. It is not intended to be a complete guide to dental materials science.

The most frequently used materials in restorative dentistry are amalgam, composite resin, glass isonomer cement, resin-isonomer cement, porcelain (ceramic), porcelain (fused-to-metal), gold alloys (noble) and nickel or cobalt-chrome (base-metal) alloys. Each material has its own advantages and disadvantages, benefits and risks. These and other relevant factors are compared in the attached matrix titled "Comparisons of Restorative Dental Materials." A Glossary of Terms" is also attached to assist the reader in understanding the terms used.

The statements made are supported by relevant, credible dental research published mainly between 1993 - 2001. In some cases, where contemporary research is sparse, we have indicated our best perceptions based upon information that predates 1993. The reader should be aware that the outcome of dental treatment or durability of a restoration is not solely a function of the material from which the restoration was made. The durability of any restoration is influenced by the dentist's technique when placing the restoration, the ancillary materials used in the procedure, and the patient's cooperation during the procedure. Following restoration of the teeth, the longevity of the restoration will be strongly influenced by the patient's compliance with dental hygiene and home care, their diet and chewing habits.

Both the public and the dental profession are concerned about the safety of dental treatment and any potential health risks that right be associated with the materials used to restore the teeth. All materials commonly used (and listed in this fact sheet) have been shown -- through laboratory and clinical research, as well as through extensive clinical use -- to be safe and effective for the general population. The presence of these materials in the teeth does not cause adverse health problems for the majority of the population. There exist a diversity of various scientific opinions regarding the safety of mercury dental amalgams. The research literature in peer-reviewed scientific journals suggests that otherwise healthy women, children and diabetics are not at increased risk for exposure to mercury from dental amalgams. Although there are various opinions with regard to mercury risk in pregnancy, diabetes, and children, these opinions are not scientifically conclusive and therefore the dentist may want to discuss these opinions with their patients. There is no research evidence that suggests pregnant women, diabetics and children are at increased health risk from dental amalgam fillings in their mouth. A recent study reported in the JADA factors in a reduced tolerance (1/50

th of the WHO safe limit)

for exposure in calculating the amount of mercury that right be taken in from dental fillings. This level falls below the established safe limits for exposure to a low concentration of mercury or any other released component from a dental restorative material. Thus, while these sub-populations ray be perceived to be at increased health risk from exposure to dental restorative materials, the scientific evidence does not support that claim. However, there are individuals who may be susceptible to sensitivity, allergic or adverse reactions to selected materials. As with all dental materials, the risks and benefits should be discussed with the patient, especially with those in susceptible populations.

There are differences between dental materials and the individual elements or components that compose these materials. For example, dental amalgam filling material is composed mainly of mercury (43-54%) and varying percentages of silver, tin, and copper (46-57%). It should be noted that elemental mercury is listed on the Proposition 65 list of known toxins and carcinogens. Like all materials in our environment, each of these elements by themselves is toxic at sore level of concentration if they are taken into the body. When they are mixed together, they react chemically to form a crystalline metal alloy. Small amounts of free mercury ray be released from amalgam fillings over tire and can be detected in bodily fluids and expired air. The important question is whether any free mercury is present in sufficient levels to pose a health risk. Toxicity of any substance is related to dose, and doses of mercury or any other element that ray be released from dental amalgam fillings falls far below the established safe levels as stated in the 1999 US Health and Human Service Toxicological Profile for Mercury Update.

All dental restorative materials (as well as all materials that we come in contact with in our daily life) have the potential to elicit allergic reactions in hypersensitive individuals.

1 These rust be assessed on a case-by-case basis, and susceptible individuals should avoid contact with allergenic materials. Documented reports of

allergic reactions to dental amalgam exist (usually manifested by transient skin rashes in individuals who have come into contact with the material), but they are atypical. Documented reports of toxicity to dental amalgam exist, but they are rare. There have been anecdotal reports of toxicity to dental amalgam and as with all dental material risks and benefits of dental amalgam should be discussed with the patient, especially with those in susceptible populations.

Composite resins are the preferred alternative to amalgam in many cases. They have a long history of biocompatibility and safety. Composite resins are composed of a variety of complex inorganic and organic compounds, any of which right provoke allergic response in susceptible individuals. Reports of such sensitivity are atypical. However, there are individuals who ray be susceptible to sensitivity, allergic or adverse reactions to composite resin restorations. The risks and benefits of all dental materials should be discussed with the patient, especially with those in susceptible populations. Other dental materials that have elicited significant concern among dentists are nickel-chromium-beryllium alloys used predominantly for crowns and bridges. Approximately 10% of the female population are alleged to be allergic to nickel.

2 The incidence of allergic response to dental restorations made from nickel

alloys is surprisingly rare. However, when a patient has a positive history of confirmed nickel allergy, or when such hypersensitivity to dental restorations is suspected, alternative metal alloys ray be used. Discussion with the patient of the risks and benefits of these materials is indicated.

Patient Acknowledgement of Dental Materials Fact Sheet

I, _____________________________________________, acknowledge that I have received a copy of the Dental Materials Fact Sheet dated Patient NameOctober 2001 from SLO Dental

SLO DentalNOTICE 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 04/14/03, 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 students, 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 $1.00 for each page, $0.00 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 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 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: Lori Perry

Telephone: (805) 547-7010 Fax: (805) 547-7014

1551 Bishop Street, Suite D-420, San Luis Obispo, CA Address:

© 2002 American Dental Association All Rights Reserved Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.

This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).