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NOTICE OF PRIVACY PRACTICES
Signature Orthodontics of Pittsburgh
Emily Chou DMD, Dominic Raggi DMD
Effective Date: January 1, 2026

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.

THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.


CONTACT INFORMATION

For more information about our privacy practices, questions or concerns, or to obtain additional copies of this Notice, please contact:

  • Privacy Officer: Matthew A. Spady, HEM, CHPSE
  • Telephone: 724-473-0462
  • Fax: n/a
  • Email: support@hcspittsburgh.com
  • Address: P.O. Box 413, Portersville, PA 16051

OUR LEGAL DUTY

We are required by law to maintain the privacy and security of your protected health information ("PHI") in accordance with the Health Insurance Portability and Accountability Act (HIPAA), as amended, and applicable state law.

We are required to provide you with this Notice explaining our legal duties, privacy practices, and your rights regarding your PHI. We must follow the terms of this Notice while it is in effect.

This Notice applies to all PHI we create, receive, maintain, or transmit, whether oral, written, or electronic. We maintain physical, administrative, and technical safeguards to protect your PHI from loss, misuse, unauthorized access, or disclosure.

We reserve the right to change this Notice and our privacy practices at any time, as permitted by law. Any changes will apply to all PHI we maintain, including information created or received before the change. If we make a material change, a revised Notice will be made available in our office, on our website (if applicable), and upon request. The effective date will be listed at the top of the Notice.

USES AND DISCLOSURES OF YOUR HEALTH INFORMATION

Treatment

We may use and disclose your PHI without your authorization to provide, coordinate, or manage your dental and related health care. This may include sharing information with dentists, specialists, laboratories, pharmacies, or other healthcare providers involved in your care.

Payment

We may use and disclose your PHI to obtain payment for dental services provided, including billing insurance plans, benefit determinations, claims management, and collection activities.

Health Care Operations

We may use and disclose your PHI for health care operations, including:

  • Quality assessment and improvement activities
  • Reviewing provider performance, competence, and qualifications
  • Accreditation, licensing, and credentialing activities
  • Audits, compliance reviews, and legal services
  • Fraud and abuse detection and prevention
  • Business planning, management, administration, billing, customer service, and complaint resolution
  • Creating de-identified information or limited data sets for health care operations, public health, and research

We may disclose PHI to another healthcare provider or health plan for their health care operations activities when legally permitted and when there is an existing or prior relationship with you.

YOUR AUTHORIZATION

You or your personal representative may give us written authorization to use or disclose your PHI for purposes not described in this Notice. You may revoke your authorization at any time in writing, except to the extent we have already relied on it. We do not use or disclose PHI for marketing, fundraising, or sale of information without your authorization. You may opt out of authorized communications at any time.

INDIVIDUALS INVOLVED IN YOUR CARE

We may share relevant PHI with family members, friends, or others involved in your care or payment for care, unless you object. We may also disclose limited information to assist with disaster relief or emergency notification efforts when appropriate.

APPOINTMENT REMINDERS & HEALTH COMMUNICATIONS

We may contact you by phone, voicemail, text message, email, or mail to provide appointment reminders, treatment information, and practice-related communications. You may request alternative or confidential communication methods.

PLAN SPONSORS

If your dental benefits are provided through an employer-sponsored plan, we may disclose summary health information to the plan sponsor as permitted by law.

PUBLIC HEALTH, LEGAL, AND SAFETY DISCLOSURES

We may use or disclose your PHI without authorization when required or permitted by law, including for:

  • Public health reporting and vital statistics
  • Reporting abuse, neglect, or domestic violence
  • Health oversight activities
  • Research, when approved by law
  • Judicial and administrative proceedings
  • Law enforcement purposes
  • Coroners, medical examiners, funeral directors, and organ procurement organizations
  • Military, national security, and correctional institution activities
  • Workers’ compensation programs
  • Preventing a serious and imminent threat to health or safety

If another law provides greater privacy protection than HIPAA we will follow the more stringent law.

SPECIAL PROTECTIONS FOR CERTAIN HEALTH INFORMATION

Substance Use Disorder (SUD) Records

Records related to substance use disorder diagnosis, treatment, or referral are protected by federal law (42 CFR Part 2). These records may not be used or disclosed without your specific written authorization, except as permitted or required by law. Such records are not disclosed for law enforcement, legal proceedings, or administrative actions without a court order or your authorization, except as allowed by law.

Reproductive Health Information

We do not use or disclose reproductive health information for the purpose of investigating or imposing liability related to lawful reproductive health care. Disclosures will only be made as permitted by HIPAA and applicable state law and never for prohibited purposes.

Other Highly Confidential Information

Additional privacy protections may apply to information related to:

  • HIV/AIDS
  • Mental health treatment
  • Genetic testing (GINA)
  • Sexually transmitted infections
  • Child or adult abuse or neglect, including sexual assault

BUSINESS ASSOCIATES

We may disclose PHI to our business associates who perform services on our behalf. Business associates are required by law and contract to safeguard your information and may only use or disclose it as permitted.

BREACH NOTIFICATION

We may use your contact information to notify you of a breach of your unsecured PHI as required by law.

YOUR RIGHTS

You have the right to:

  • 1. Inspect and obtain a copy of your health records
  • 2. Request amendments to your health information
  • 3. Receive an accounting of certain disclosures
  • 4. Obtain a paper or electronic copy of this Notice
  • 5. Request restrictions on certain uses or disclosures
  • 6. Request confidential communications
  • 7. Choose whether to authorize disclosures for marketing or fundraising
  • 8. Revoke authorizations at any time (with limited exceptions)
  • 9. Opt out of fundraising communications
  • 10. File a complaint without fear of retaliation

To exercise these rights, contact our Privacy Officer.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with us or with:

  • U.S. Department of Health and Human Services
  • Office for Civil Rights
  • 200 Independence Avenue, SW
  • Washington, DC 20201
  • Phone: 1-800-368-1019
  • Website: www.hhs.gov/ocr

We will not retaliate against you for filing a complaint.

This Notice of Privacy Practices is intended to comply with HIPAA, 42 CFR Part 2, and applicable state law as of 2026.

PATIENT ACKNOWLEDGMENT OF NOTICE OF PRIVACY PRACTICES
Signature Orthodontics of Pittsburgh
Emily Chou DMD, Dominic Raggi DMD

ACKNOWLEDGMENT OF RECEIPT

I acknowledge that I have been provided with a copy of the Notice of Privacy Practices (NPP) for Signature Orthodontics of Pittsburgh, effective January 1, 2026.

I understand that this Notice describes how my protected health information (PHI) may be used and disclosed, how I may access my information, and my rights regarding the privacy of my health information, in accordance with the Health Insurance Portability and Accountability Act (HIPAA), as amended, and applicable federal and state law.

I understand that the Notice includes specific information regarding:

  • My privacy rights under HIPAA
  • How my dental and medical information may be used for treatment, payment, and health care operations
  • Special privacy protections for certain sensitive information, including substance use disorder records (42 CFR Part 2) and reproductive health information
  • How to file a complaint if I believe my privacy rights have been violated

I understand that Signature Orthodontics of Pittsburgh reserves the right to change its Notice of Privacy Practices and that a current copy will be available in the office, on the practice website (if applicable), and upon request.

  • *By typing my name below in the signature fields, I acknowledge that I have read and understand the updated Privacy Notice. I understand that typing my name constitutes my electronic signature and has the same legal effect as a handwritten signature.

PATIENT INFORMATION

Signature

PERSONAL REPRESENTATIVE (If Applicable)

If this acknowledgment is signed by a personal representative of the patient, please complete the following:

Signature


FOR OFFICE USE ONLY

If acknowledgment is not obtained:


This acknowledgment is maintained in the patient’s record as required by HIPAA. Refusal to sign does not affect the patient’s ability to receive treatment.