Tooth Truck Privacy Practice

Ronald McDonald Care Mobile of the Ozarks The Tooth Truck, Inc.

NOTICE OF PRIVACY PRACTICE

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 September 1, 2013 and will remain in effect until we replace it.

We reserve the right to change our privacy practices and applicable law permits the terms of this Notice to be
changed at any time. 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 health operations.

Examples are:

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 healthcare professionals, evaluating practitioner and provider performance,
conducting training programs, accreditation, certification, licensing or credentialing activities. We are obligated to
notify you in the event of a breach of unsecured Protected Health Information (PHI).

Your Authorizations: 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 written 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 described in this Notice.
You have a right to an electronic copy of your records. You may request a copy at any time. In the event you pay in
full for a service out of pocket, you now have the right to request that we do not disclose treatment information for
this service to a health plan.

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 Protected Health Information (PHI) for marketing
purposes without your written authorization. We may use your PHI for fundraising purposes; however, you have
the right to opt out by informing us in writing.

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.

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The following trademarks used herein are owned by McDonald's Corporation and its affiliates: Ronald McDonald House Charities, Ronald McDonald House Charities Logo, RMHC, Ronald McDonald House, Ronald McDonald House Logo, Ronald McDonald Care Mobile, Ronald McDonald Care Mobile Logo, McDonald's. The Tooth Truck name and logo are owned by The Tooth Truck, Inc.