Picasso Aesthetic and Cosmetic Dental Spa NOTICE OF PRIVACY PRACTICES

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NOTCE OF PRVACY PRACTCES THS NOTCE DESCRBES HOW HEALTH NFORMATON ABOUT YOU MAY BE USED AND DSCLOSED AND HOW YOU CAN GET ACCESS TO THSNFORMATON. Please review it carefully THE PRVACY OF YOUR HEALTH NFORMATON S MPORTANT 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 (04114/03), and will remain in effect until we replace it. We reserved 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 DSCLOSURES OF HEALTH NFORMATON We use and disclose health information about you for treatment, payment, and healthcare operations. For example: Treatment: We may use and 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 health care professionals, evaluating practitioners and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. Your Authorization: n addition to our use of our 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. f 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 nvolved 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, or general condition, or death. f 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. n 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, counter intelliqence. and other national security activities. We may disclose to correctional institutions or law enforcement officials 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). PATENT RGHTS 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. f you request copies, we will charge you $1.00 for each page, $15.00 per hour for staff time to locate and Copy your health information, and postage if you want the copies mailed to you. f you request an alternative format, we will charge a cost-based fee for providing your health information in that format. f 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 Accountlnq: 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, health care operations and certain other activities, for the last 6 years, but not before April 14, 2003. f 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. Restrictions: 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 Communications: 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 of how payments will be handled under the alternative means or location you request. Amendment: You have the right to request that we amend your 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: f you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form. QUESTONS AND COMPLANTS f 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 may also 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 or Human Services. Contact Officer: Jeffrey Rubin Telephone 239-431-5666 Fax: 239-431-5660 Address: 5651 Naples Blvd Naples FL 34109 E-mail: rubin1dds@comcast.net

ACKNOWLEDGEMENT OF RECEPT OF NOTCE OF PRVACY PRACTCES ** You May Refuse To Sign This. Acknowledgement **,, have received a copy of this office's Notice of Privacy Practices. (Signature) (Date).:. Please indicate the person(s) whom you consent to have access to your Protected Health nformation:.:. f this Consent is signed by a personal representative on behalf of the patient, complete the following: > Personal Representative's Name: > Relationship to Patient: FOR OFFCE USE ONLY We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: ndividual refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please Specify) Revised 9/09

PATENT BSPHOSPHONATES DSCLOSURE FOR DENTAL PROCEDURES Patients should know that there is a significant risk of future complications associated with certain dental procedures if they have been on these medications. Bisphosphonate medications appear to adversely affect the blood supply to bone, thereby reducing or eliminating its ordinary excellent capacity for healing. This risk is increased after surgery, especially from extractions, implant placement, or other invasive procedures that might cause trauma to the bone. Osteonecrosis may result. This is a smoldering long-term, destructive process in the jaw bone that is often very difficult or impossible to eliminate. t is very important to know if you are taking or have taken these medications: Fosamax, Actonel, Boniva, Zometa, Aredia, Neridronate, Olpadronate, Didronel, Clorodronate, Tiludronate, or any other Bisphosphonate. Patient Name am presently taking: have taken: From: To: am not on any of this class of medication. Patient initials Patient Signature Date

5651 Naples Blvd Naples, FL 34109 nsurance: Tender: Financial Policies and Signature on File Agreement Providing the highest standards in dental care. Your dental insurance is your responsibility. The insured or the guarantor is responsible for the total treatment fees. We are in-network providers for most insurance companies. As a courtesy to you, we will file your claim and after dental insurance has paid, a statement is mailed to the address on record if a remaining balance exists. Payment of the remaining balance is expected within 15 days of the statement. f your insurance company does not pay the claim within 45 days, it will be your responsibility to pay the outstanding balance. Reimbursement by your insurance company is dictated by a contract between your employer and the insurance company. We are not a party to any of these contracts. Cash, personal checks, debit Visa, MC, Amex and Disc are accepted Optional financing through Care Credit, Chase and Citibank Please be advised that returned checks will be subject to a service charge. OVER DUE BALANCES: Accounts with a unpaid balance past 120 days will be sent to a collection agency. At that time, you will be responsible for any and all cost incurred in the collection of your debt. Broken Appointments: Appointments not kept or rescheduled, with less than 48 hours notice are considered broken appointments. Broken appointments prevent others from receiving the dental care they deserve. Please be considerate and inform us in advance if you need to reschedule your appointment. We reserve the right to charge $50.00 for broken appointments. Dr Rubin understands temporary financial problems may affect timely payment of your balance. n those situations, we encourage you to communicate any such problems immediately so that we may assist you in the management of your account. CONSENT & AUTHORZATON: agree to pay all related fees. Fees not covered by my dental insurance will be promptly paid upon notification from this office. have read and understand this document, outlining financial policies of Picasso Aesthetic and Cosmetic Dental Spa. agree to abide by the policies outlined herein. Name: Signature Date: Relationship to Patient Reviewed By: Date:

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