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Notice of Privacy Practices for Protected Health Information
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! With your consent, the practice is permitted by federal privacy laws
to make uses and disclosures of your health information for purposes of
treatment, payment, and health care operations. Protected health
information is the information we create and obtain in providing our
services to you. Such information may include documenting your symptoms,
examination and test results, diagnoses, treatment, and applying for
future care or treatment. It also includes billing documents for those
services.
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Example of uses of your health information for treatment
purposes:
A hygienist obtains treatment information about you and records it in
a health record. During the course of your treatment, the dentist
determines a need to consult with another specialist in the area. The
dentist will share the information with such specialist and obtain
input.
Example of use of your health information for payment purposes:
We submit a request for payment to your health insurance company. The
health insurance company requests information from us regarding care
given. We will provide information to them about you and the care given.
Example of Use of Your Information for Health Care Operations:
We obtain services from our insurers or other business associates
such as quality assessment, quality improvement, outcome evaluation,
protocol and clinical guidelines development, training programs, legal
services, and insurance. We will share information about you with such
insurers or other business associates as necessary to obtain these
services.
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Your Health Information Rights
The health record we maintain and billing records are the physical
property of the practice. The information in it, however, belongs to
you. You have a right to:
Request a restriction on certain uses and disclosures of your health
information by delivering the request in writing to our office. We are
not required to grant the request but we will comply with any request
granted;
- Obtain a paper copy of this Notice of Privacy Practices for
Protected Health Information ("Notice") by making a request at our
office;
- Request that you be allowed to inspect and copy your health record
and billing record—you may exercise this right by delivering the request
in writing to our office;
- Appeal a denial of access to your protected
health information except in certain circumstances;
- Request that your
health care record be amended to correct incomplete or incorrect
information by delivering a written request to our office;
- File a
statement of disagreement if your amendment is denied, and require that
the request for amendment and any denial be attached in all future
disclosures of your protected health information;
- Obtain an accounting of disclosures of your health information as
required to be maintained by law by delivering a written request to our
office. An accounting will not include internal uses of information for
treatment, payment, or operations, disclosures made to you or made at
your request, or disclosures made to family members or friends in the
course of providing care;
- Request that communication of your health
information be made by alternative means or at an alternative location
by delivering the request in writing to our office; and,
- Revoke
authorizations that you made previously to use or disclose information
except to the extent information or action has already been taken by
delivering a written revocation to our office.
If you want to exercise any of the above rights, please contact our
office in person or in writing, during normal business hours.
Our privacy advocate will provide you with assistance on the steps to take to
exercise your rights.
You have the right to review this Notice
before signing the consent authorizing use and disclosure of your
protected health information for treatment, payment, and health care
operations purposes. |
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Our Responsibilities
The practice is required to:
- Maintain the privacy of your health information as required by law;
- Provide you with a notice of our duties and privacy practices as to
the information we collect and maintain about you;
- Abide by the terms of this Notice;
- Notify you if we cannot accommodate a requested restriction or
request; and
- Accommodate your reasonable requests regarding methods to communicate
health information with you.
We reserve the right to amend, change, or eliminate provisions in our
privacy practices and access practices and to enact new provisions
regarding the protected health information we maintain. If our
information practices change, we will amend our Notice. You are entitled
to receive a revised copy of the Notice by calling and requesting a copy
of our "Notice" or by visiting our office and picking up a copy.
To Request Information or File a Complaint
If you have
questions, would like additional information, or want to report a
problem regarding the handling of your information, you may
contact our
privacy advocate.
Additionally, if you believe your privacy rights have been violated, you
may file a written complaint at our office by delivering the written
complaint to You may also file a complaint by mailing it or e-mailing it
to the Secretary of Health and Human Services.
- We cannot, and will not, require you to waive the right to file a
complaint with the Secretary of Health and Human Services (HHS) as a
condition of receiving treatment from the practice.
- We cannot, and will not, retaliate against you for filing a complaint
with the Secretary.
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Other Disclosures and Uses
Notification
Unless you object, we may use or disclose your protected health
information to notify, or assist in notifying, a family member, personal
representative, or other person responsible for your care, about your
location and about your general condition.
Communication with Family
Using our best judgment, we may disclose to a family member, other
relative, close personal friend, or any other person you identify,
health information relevant to that person's involvement in your care or
in payment for such care if you do not object or in an emergency.
Food and Drug Administration (FDA)
We may disclose to the PDA your protected health information relating to
adverse events with respect to products and product defects, or
post-marketing surveillance information to enable product recalls,
repairs, or replacements.
Workers Compensation
If you are seeking compensation through Workers Compensation, we may
disclose your protected health information to the extent necessary to
comply with laws relating to Workers Compensation.
Public Health
As required by law, we may disclose your protected health information to
public health or legal authorities charged with preventing or
controlling disease, injury, or disability.
Abuse & Neglect
We may disclose your protected health information to public authorities
as allowed by law to report abuse or neglect.
Correctional Institutions
If you are an inmate of a correctional institution, we may disclose to
the institution, or its agents, your protected health information
necessary for your health and the health and safety of other
individuals.
Law Enforcement
We may disclose your protected health information for law enforcement
purposes as required by law, such as when required by a court order, or
in cases involving felony prosecutions, or to the extent an individual
is in the custody of law enforcement.
Health Oversight
Federal law allows us to release your protected health information to
appropriate health oversight agencies or for health oversight
activities.
Judicial/Administrative Proceedings
We may disclose your protected health information in the course of any
judicial or administrative proceeding as allowed or required by law,
with your consent, or as directed by a proper court order.
Other Uses
Other uses and disclosures besides those identified in this Notice will
be made only as otherwise authorized by law or with your written
authorization and you may revoke the authorization as previously
provided.
Effective Date: February 1, 2006
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