NOTICE OF PRIVACY PRACTICES

GLADIOLA DENTAL CARE - NOTICE OF PRIVACY PRACTICES

Efective Date: February 16, 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.

Our Commitment to Your Privacy

This dental practice is required by law to maintain the privacy of your protected health information (“PHI”) and to provide you with this Notice of Privacy Practices explaining our legal duties and privacy practices.

We are required to: Maintain the privacy of your health information, Provide you with this Notice of our legal duties and privacy practices, Follow the terms of the Notice currently in effect

We reserve the right to change our privacy practices and the terms of this Notice at any time, as permitted by law.

How We May Use and Disclose Your Health Information

We may use and disclose your protected health information for the following purposes:

1. Treatment: We may use and disclose your health information to provide, coordinate, or manage your dental care and related services.

Examples include: Discussing your condition with specialists or referring providers, Reviewing your medical history to determine safe treatment, Sharing necessary information for care coordination

1. Payment: We may use and disclose your health information to obtain payment for services provided to you.

Examples include: Submitting claims to your insurance company, Verifying eligibility or benefits, Collection of outstanding balances

1. Health Care Operations: We may use and disclose your information for practice operations, including: Quality assessment and improvement, Staff training, Business planning and administrative activities, Compliance and risk management

Other Uses and Disclosures Permitted or Required by Law

We may disclose your health information in certain situations without your authorization, including: Public health reporting, Health oversight activities, Workers’ compensation claims, Law enforcement purposes (as required by law), To prevent a serious threat to health or safety

Substance Use Disorder (SUD) Treatment Records (42 C.F.R. Part 2 Protected Information)

Substance Use Disorder treatment records created by certain federally assisted treatment programs are subject to additional federal confidentiality protections under 42 C.F.R. Part 2 (“Part 2 Records”).

If we receive or maintain any information about you from a substance use disorder treatment program covered by Part 2:

If Received Through General Consent: If you provided general written consent to the Part 2 Program allowing disclosure for treatment, payment, or health care operations, we may use and disclose those records for those purposes as described in this Notice. However, those records remain subject to the heightened confidentiality protections required by Part 2.

If Received Through Specific Consent: If we receive your Part 2 Records through specific written consent provided to us or another party, we will use and disclose those records only as expressly permitted by your written consent.

Legal Proceedings Protection: In no event will we use or disclose your Part 2 Records, or any testimony describing the contents of those records, in any civil, criminal, administrative, or legislative proceeding by any Federal, State, or local authority against you unless: 1. You have provided specific written authorization; or 2. A court issues a proper order after providing you notice and an opportunity to be heard, consistent with Part 2 requirements.

If state law provides stronger confidentiality protections, we will follow the more stringent standard.

Uses and Disclosures Requiring Your Written Authorization

We will obtain your written authorization for: Uses or disclosures not otherwise described in this Notice, Most uses of psychotherapy notes (if applicable), Certain marketing communications, Sale of protected health information (we do not sell patient information)

You may revoke your authorization in writing at any time.

Your Rights Regarding Your Health Information

You have the right to:

1. Inspect and Obtain Copies: You may request access to your dental records.
2. Request an Amendment: If you believe information in your record is incorrect or incomplete, you may request a correction.
3. Request Restrictions: You may request limits on how we use or disclose your information. While we are not required to agree to all restrictions, we will comply when legally required.
4. Request Confidential Communications: You may request we contact you in a specific way (e.g., only at work, only by mail).
5. Receive an Accounting of Disclosures: You may request a list of certain disclosures made outside of treatment, payment, or operations.
6. Receive a Paper Copy: You may request a paper copy of this Notice at any time.

Our Responsibilities

We are required to: Maintain the privacy and security of your health information, Notify you if a breach occurs that may have compromised your information, Follow the privacy practices described in this Notice

Complaints

If you believe your privacy rights have been violated, you may file a complaint with our office or with the U.S. Department of Health and Human Services. You will not be retaliated against for filing a complaint. Practice Contact Information:

Privacy Officer: Dr. Aleksandra Glodek DMD PhD Phone: 847-362-4994

Address: 221 N Milwaukee Ave, Libertyville IL 60048