SUMMARY OF NOTICE OF PRIVACY PRACTICES (PROVIDER)
The Notice of Privacy Practices covers services provided to you by our office.
We are required by law to maintain the privacy of protected health information
and to provide you with the Notice of our legal duties and privacy practices
with respect to protected health information. Protected health information. is
information about you, including demographic information, that may identify you
and that relates to your past, present or future physical or mental health or
condition and related health care services.
The Notice describes how we may use and disclose your protected health information
to carry out treatment, payment or health care operations. Other uses and disclosures
of your protected health information will be made only with your written authorization,
unless otherwise permitted or required by law. The Notice also describes your
rights to access and control your protected health information. Further, the
Notice informs you of your rights to complain to us or the Secretary of Health
and Human Services if you believe your privacy rights have been violated by us.
We are required to abide by the terms of the Notice. We may change the terms
of our notice, at any time. The new notice will be effective for all protected
health information that we maintain at that time. Upon your request, we will
provide you with any revised Notice. You may contact our office by, calling our
Office Manager and requesting that a revised copy be sent to you in the mail,
or asking for one at the time of your next appointment.
Please read the attached Notice carefully.
NOTICE OF PRIVACY PRACTICES
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.
If you have any questions about this Notice please contact: our Privacy Contact
who is the OFFICE MANAGER.
We are required by law to maintain the privacy of protected health information
and to provide you with this Notice of our legal duties and privacy practices
with respect to protected health information. .Protected health information.
is information about you, including demographic information, that may identify
you and that relates to your past, present or future physical or mental health
or condition and related health care services.
We are required to abide by the terms of this Notice currently in effect. We
may change the terms of our notice, at any time. The new notice will be effective
for all protected health information that we maintain at that time. Upon your
request, we will provide you with any revised Notice by, calling our Privacy
Contact and requesting that a revised copy be sent to you in the mail, or asking
for one at the time of your next appointment.
1. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
Uses and Disclosures of Protected Health Information for Treatment, Payment,
or Operations
Your protected health information may be used by your dentist for treatment,
payment and health care operations as described in this Section 1 without authorization
from you. Your protected health information may be used and disclosed by your
dentist, our office staff and others outside of our office that are involved
in your care and treatment for the purpose of providing health care services
to you. Your protected health information may also be used and disclosed to pay
your health care bills and to support the operation of the dentist.s practice.
Following are examples of the types of uses and disclosures of your protected
health care information that the dentist.s office is permitted to make without
your specific authorization. These examples are not meant to be exhaustive, but
to describe the types of uses and disclosures that may be made by our office.
Treatment: We will use and disclose your protected health information
to provide, coordinate, or manage your health care and any related services.
This includes the coordination or management of your health care with a third
party, consultations with another dentist, or your referral to another dentist
for your diagnosis and treatment.
Payment: Your protected health information will be used, as
needed, to obtain or provide payment for your dental services, including disclosures
to other entities. This may include certain activities that your health insurance
plan may undertake before it approves or pays for the services we recommend for
you such as making a determination of eligibility or coverage for insurance benefits,
reviewing services provided to you, and undertaking utilization review activities.
Operations: We may use or disclose, as needed, your protected
health information in order to support the business activities of your dentist.s
practice. These activities include, but are not limited to: quality assessment
and improvement activities; reviewing the competence or qualifications of professionals;
securing stop-loss or excess of loss insurance; obtaining legal services or conducting
compliance programs or auditing functions; business planning and development;
business management and general administrative activities, such as compliance
with the Health Insurance Portability and Accountability Act; resolution of internal
grievances; due diligence in connection with the sale or transfer of assets of
your dentist.s practice; creating de-identified health information; and conducting
or arranging for other business activities.
For example, we may use a sign-in sheet at the registration desk where you will
be asked to sign your name and indicate your treating provider. We may also call
you by name in the waiting room when your treating provider is ready to see you.
We may use or disclose your protected health information, as necessary, to contact
you to remind you of your appointment.
We will share your protected health information with third party .business associates.
that perform various activities (e.g., billing, transcription services, accounting
services, legal services) for the practice. Whenever an arrangement between our
office and a business associate involves the use or disclosure of your protected
health information, we will have a written contract that contains terms that
will protect the privacy of your protected health information.
We may use or disclose your protected health information, as necessary, to provide
you with information about a product or service to encourage you to purchase
or use the product or services for the following limited purposes: (1) to describe
our participation in a dentist network or health plan network, or to describe
if, and the extent to which, a product or service (or payment for such product
or service) is provided by our practice or included in a plan of benefits; (2)
for your treatment; or (3) for your case management or care coordination, or
to direct or recommend alternative treatments, therapies, dentists, or settings
of care.
In addition, we may disclose your protected health information to another provider,
health plan, or health care clearinghouse for limited operational purposes of
the recipient, as long as the other entity has, or has had, a relationship with
you. Such disclosures shall be limited to the following purposes: quality assessment
and improvement activities, population-based activities relating to improving
health or reducing health care costs, case management, conducting training programs,
accreditation, certification, licensing, credentialing activities, and health
care fraud and abuse detection and compliance programs.
Uses and Disclosures of Protected Health Information Based upon Your Written
Authorization
Other uses and disclosures of your protected health information will be made
only with your written authorization, unless otherwise permitted or required
by law. You may revoke this authorization, at any time, in writing, except to
the extent that your dentist or the provider.s practice has taken an action in
reliance on the use or disclosure indicated in the authorization.
2. YOUR RIGHTS
Following is a statement of your rights with respect to your protected health
information and a brief description of how you may exercise these rights.
You have the right to inspect and copy your protected health information. This
means you may inspect and obtain a copy of protected health information about
you that is contained in your chart, including medical and billing records and
any other records that your dentist and the practice uses for making decisions
about you.
Under federal law, however, you may not inspect or copy the following records:
information compiled in reasonable anticipation of, or use in, a civil, criminal,
or administrative action or proceeding; and protected health information that
is subject to law that prohibits access to protected health information. Depending
on the circumstances, a decision to deny access may be reviewable. In some circumstances,
you may have a right to have this decision reviewed. Please contact our Privacy
Contact if you have questions about access to your medical record.
You have the right to request a restriction of your protected health information.
This means you may ask us not to use or disclose any part of your protected health
information for the purposes of treatment, payment or healthcare operations.
You may also request that any part of your protected health information not be
disclosed to family members or friends who may be involved in your care or for
notification purposes as described in this Notice. Your request must state the
specific restriction requested and to whom you want the restriction to apply.
Your dentist is not required to agree to a restriction that you may request.
If your dentist believes it is in your best interest to permit use and disclosure
of your protected health information, your protected health information will
not be restricted. If your dentist does agree to the requested restriction, we
may not use or disclose your protected health information in violation of that
restriction unless it is needed to provide emergency treatment. With this in
mind, please discuss any restriction you wish to request with the office privacy
contact. You may request a restriction by speaking with the office manager who
is the privacy contact.
You have the right to request to receive confidential communications from us
by alternative means or at an alternative location. We will accommodate reasonable
requests. We may also condition this accommodation by asking you for information
as to how payment will be handled or specification of an alternative address
or other method of contact. We will not request an explanation from you as to
the basis for the request. Please make this request in writing to our Privacy
Contact.
You may have the right to have your provider amend your protected health information.
This means you may request an amendment of protected health information about
you in a designated record set for as long as we maintain this information. In
certain cases, we may deny your request for an amendment. If we deny your request
for amendment, you have the right to file a statement of disagreement with us
and we may prepare a rebuttal to your statement and will provide you with a copy
of any such rebuttal. Please contact our Privacy Contact to determine if you
have questions about amending your medical record.
You have the right to receive an accounting of certain disclosures we have made,
if any, of your protected health information. This right applies to disclosures
for purposes other than treatment, payment or healthcare operations as described
in this Notice. It excludes disclosures we may have made to you, for a facility
directory, to family members or friends involved in your care, or for notification
purposes, or disclosures for which you have signed an authorization. You have
the right to receive specific information regarding these disclosures that occurred
after April 14, 2003. You may request a shorter timeframe. The right to receive
this information is subject to certain exceptions, restrictions and limitations.
You have the right to obtain a paper copy of this Notice from us, upon request,
even if you have agreed to accept this Notice electronically.
3. COMPLAINTS
You may complain to us or to the Secretary of Health and Human Services if you
believe your privacy rights have been violated by us. You may file a complaint
with us by notifying our Privacy Contact of your complaint. We will not retaliate
against you for filing a complaint.
You may contact our Privacy Contact, the OFFICE MANAGER for further information
about the complaint process.
This Notice was published and becomes effective on as of Agust 19, 2009.