New Patient Forms

Notice of Privacy Practices

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program requiring all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information.

The following is an explanation of how we are required to maintain the privacy of our health information and how we may use and disclose your health information. We may use and disclose your medical records only for each of the following purposes: treatment, payment, and health care operations.

• Treatment means providing coordination or managing health care and related services by one or more health care providers. An example of this would include sending documents to an oral surgeon for a tooth extraction or contacting your regular dentist regarding treatment.
• Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your treatment to your insurance company for payment.
• Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Any other uses and disclosures will be made only with your written authorization.

You may revoke such authorization in writing, and we are required to honour and abide by that written request, except to the extent that we have already taken actions relying on your authorization. You have the following rights with respect to your protected health information, which you may exercise by presenting a written request to our Privacy Officer:

• The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
• The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
• The right to inspect and copy your protected health information.
• The right to amend your protected health information
• The right to receive an accounting of disclosures of protected health information.
• The right to obtain a paper copy of this notice from us upon request.

Notice of Privacy Practices – SMS Messaging

Effective Date: October 14, 2025

Orthodontic Specialists of Lake Oswego / Dr. Kari Borgen respects your privacy and is committed to protecting
your personal information.

This Privacy Policy explains how we collect, use, and share information when you opt in to receive SMS Messages from us.

Information on We Collect

When you Opt-In to receive SMS Messages, we collect:

• Your phone number
• Consent to send SMS Messages

How We Use Your Information

We use your information to:

• Send you SMS Messages you’ve opted in to receive
• Provide updates, promotions, or other relevant content based on your preferences
• You will receive (state expected frequency, e.g., up to 4 messages per month

Sharing Your Information

We do not share your phone number OR SMS Opt-In information with third parties for marketing purposes.

Your Rights

You can opt out of receiving SMS Messages at any me by replying with “STOP” to any messages we send you.

If you need support, reply “HELP”.

Data Security

Your information will be handled in accordance with our Privacy Policy, which can be viewed at www.lakeoswegobraces.com. We implement reasonable measures to protect your personal information from unauthorized access or disclosure. Message frequency varies. Msg& data rates may apply based on your mobile carrier’s terms. We are not responsible for any charges, errors, or delays in SMS delivery caused by your carrier or third-party service providers.

Questions? Contact Us

If you have questions or concerns about our Privacy Practices, contact us.

First Name *

Last Name *

Email *

Phone *

Consent *

I consent to receive SMS text messages from Orthodontic Specialists of Lake Oswego for appointment reminders, marketing messages and general two-way communication.

I DO NOT consent to receive SMS text messages from Orthodontic Specialists of Lake Oswego for appointment reminders, marketing messages and general two-way communication.

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