22 Sierra Drive, Martinsburg, WV 25403 · (304) 263-3131 · www.tuscaroradental.com

Effective date: October 25, 2026

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Questions about this notice or your privacy? Contact our Privacy Officer:
Jody Thomas, Privacy Officer · [(304) xxx-xxxx] · privacy@tuscaroradental.com

Your Information. Your Rights. Our Responsibilities.

In this notice, "health information" means information that identifies you and relates to your health, your dental care, or payment for your care. At Tuscarora Dental, that includes your dental and medical history, clinical notes, x-rays and 3D (CBCT) scans, digital impressions and photographs, bite and jaw-function records, treatment plans, and billing records.

At a glance

You have the right to:

• Get a copy of your paper or electronic health record
• Ask us to correct your health record
• Request confidential communications
• Ask us to limit the information we use or share
• Get a list of those with whom we've shared your information
• Get a copy of this notice
• Choose someone to act for you
• Be notified if a breach affects your information
• File a complaint if you believe your privacy rights have been violated

You have some choices in the way we use and share information when we:

• Talk with family and friends involved in your care
• Help with disaster relief
• Market our services or sell information (never without your written permission)
• Use photos, videos, or testimonials that identify you (never without your written permission)

We may use and share your information as we:

• Treat you
• Run our practice
• Bill for your services
• Help with public health and safety issues
• Do research
• Comply with the law
• Respond to organ and tissue donation requests
• Work with a medical examiner, coroner, or funeral director
• Address workers' compensation, law enforcement, and other government requests
• Respond to lawsuits and legal actions

If we have substance use disorder treatment records about you that are protected by federal law (42 CFR Part 2), we will not share that information for investigations or legal proceedings against you without (1) your written consent or (2) a court order and a subpoena. See Extra Protections for Certain Information below.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your health record

• You can ask to see or get a copy of your health record and other health information we have about you, including x-rays, scans, and photographs. If we keep the information electronically, you can ask for an electronic copy, and you can ask us to send a copy to another person or provider you choose. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee, and we will tell you the fee in advance.

Ask us to correct your health record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say "no" to your request, but we'll tell you why in writing within 60 days. If we say no, you may give us a written statement of disagreement to be added to your record.

Request confidential communications

• You can ask us to contact you in a specific way (for example, only by cell phone, no text messages, or no detailed voicemails) or to send mail to a different address.
• We will say "yes" to all reasonable requests, and we will not ask you why.
• We send appointment reminders and other messages by phone, text, and email. If you ask us to communicate with you by unencrypted email or text message, we will tell you that there is some risk the information could be read by someone else, and we will follow your choice.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say "no" if it could affect your care. If we agree, we may still share the information if you need emergency treatment.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share information about it with your health insurer for payment or our operations. We will say "yes" unless a law requires us to share that information.

Get a list of those with whom we've shared information

• You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all disclosures except those for treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

• You can ask for a paper copy of this notice at any time, even if you agreed to receive it electronically. We will provide a paper copy promptly. This notice is also available at our front desk and on our website.

Choose someone to act for you

• If someone has legal authority to act as your personal representative, such as a health care power of attorney or a legal guardian, that person can exercise your rights and make choices about your health information. For patients under 18, a parent or legal guardian generally acts as the personal representative, except where law allows the minor to act on their own behalf.
• We will make sure the person has this authority before we take any action.

Be notified of a breach

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

File a complaint if you feel your rights are violated

• You can complain to us by contacting our Privacy Officer using the information at the top of this notice.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting https://www.hhs.gov/hipaa/filing-a-complaint/index.html. This includes complaints about substance use disorder records protected by 42 CFR Part 2.
• We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care or payment for your care. Example: If someone is driving you home after sedation, we may review your after-care instructions with them. Tell us in advance if there is anyone you do not want us to talk to.
• Share information in a disaster relief situation.

If you are not able to tell us your preference — for example, if you are unconscious or still under the effects of sedation — we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

We do not maintain a patient directory.

In these cases, we never share your information unless you give us written permission:

• Marketing. We may tell you about our own services and treatment options, but we will never accept payment from another company to send you its marketing without your written permission.
• Sale of your information. We do not sell health information.
• Photos, videos, and testimonials that identify you, including in our advertising, website, or social media, or in presentations to other health care professionals. Images that cannot identify you (for example, a close-up photo of teeth with all identifying details removed) may be used for professional education.
• Most sharing of psychotherapy notes. We do not create psychotherapy notes, but this protection applies if we ever hold them.

Fundraising

• We do not use your health information for fundraising. If that ever changes, we will update this notice, and you will be able to tell us not to contact you again.
• If we have your substance use disorder treatment records protected by 42 CFR Part 2, we will give you clear and obvious notice in advance and a choice about whether to receive fundraising communications that use your Part 2 information.

Changing your mind

• If you give us written permission to use or share your information, you can change your mind at any time by telling us in writing. This will not undo any sharing we already did while relying on your permission.

Our Uses and Disclosures

How do we typically use or share your health information?

Treat you

We can use your health information and share it with other professionals who are treating you.

Examples: We send your digital scans, photographs, and prescription to a dental laboratory — or to our in-office lab — to make your crown, implant restoration, denture, or oral appliance. We share findings with your physician, ear-nose-and-throat specialist, sleep physician, or a dental specialist to coordinate airway, jaw-joint (TMD), sedation, or surgical care. We communicate with your pharmacy about prescriptions, and before prescribing certain controlled medications we check West Virginia's prescription monitoring database when state law requires it.

Run our practice

We can use and share your health information to run our practice, improve your care, train our team, and contact you when necessary.

Examples: Scheduling and appointment reminders by phone, text, or email; reviewing the quality and safety of our care; training our clinical team; licensing, credentialing, and accreditation reviews; and working with our attorneys, accountants, and consultants.

[Portions of some visits may be recorded so that secure transcription software can draft your clinical notes. If you would prefer not to be recorded, tell your provider.]

Some services are provided for us by outside companies ("business associates"), such as our practice-management software, clinical transcription, phone and text-messaging systems, email and IT providers, and billing, legal, and accounting services. They may receive your information only to do work on our behalf, and they must sign a contract agreeing to protect it.

Bill for your services

We can use and share your health information to bill and get payment from you, health or dental plans, or others responsible for payment.

Example: We give information about your treatment to your dental or medical plan so it will pay for your services or reimburse you. If an account becomes past due, we may share limited information with a collection agency.

How else can we use or share your health information?

We are allowed or required to share your information in other ways — usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes.

In all cases, including those listed below, if we have substance use disorder treatment records about you that are protected by 42 CFR Part 2, we cannot use or share information in those records in civil, criminal, administrative, or legislative investigations or proceedings against you without (1) your written consent or (2) a court order and a subpoena.

Help with public health and safety issues

We can share health information about you for certain situations such as:

• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications, or problems with dental materials and devices
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone's health or safety

Do research

We can use or share your information for health research only as the law allows — generally with your written permission, or with the approval of a research review board that has determined your privacy will be protected.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner, coroner, or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies — including providing dental records to help identify a person.

Address workers' compensation, law enforcement, and other government requests

We can use or share health information about you:

• For workers' compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law, such as the West Virginia Board of Dentistry
• For special government functions such as military, national security, and presidential protective services
• With a correctional institution or law enforcement official if you are in their custody

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena, as the law allows.

Extra Protections for Certain Information

Some federal and West Virginia laws protect certain information more strictly than HIPAA does. When they apply, we follow the stricter rule.

Substance use disorder treatment records (42 CFR Part 2)

Tuscarora Dental does not provide substance use disorder treatment, but we may receive records from a federally assisted treatment program — for example, when you or another provider sends us your health history. If we have these records:

• We will not use or share the records, or testimony about what they contain, in any civil, criminal, administrative, or legislative investigation or proceeding against you unless (1) you give written consent, or (2) a court orders it after you have been given notice and an opportunity to be heard. A court order must be accompanied by a subpoena or other legal requirement compelling disclosure before we use or share the records.
• If you signed a consent allowing the records to be used for treatment, payment, and health care operations, we may use and share them as described in this notice, except for investigations or proceedings against you as described above.
• If we received the records under a more limited consent, we will use and share them only as that consent and federal law allow.
• Our fundraising commitment for these records is described under Your Choices.

HIV-related test results

West Virginia law (W. Va. Code §16-3C-3) limits who may receive HIV-related test results. We will share them only as that law permits — for example, with your specific written release, or with health care providers who are caring for you.

Mental health information

West Virginia law (W. Va. Code §27-3-1) gives mental health treatment information additional confidentiality. When we hold this kind of information, we will share it only as that law permits.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information and to give you this notice of our legal duties and privacy practices.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in the notice currently in effect and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information, see: https://www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

Changes to the Terms of This Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website, and will show its effective date.

Effective Date

This notice takes effect on October 25, 2026 and replaces all previous versions.