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.
The Health Insurance Portability &
Accountability Act of 1996 (HIPAA) requires all health care records and other
individually identifiable health information (protected health information) used
or disclosed to us in any form, whether electronically, on paper, or orally, be
kept confidential. This federal law 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.
As required by HIPAA, we have prepared this explanation of how we are required
to maintain the privacy of your health information and how we may use and
disclose your health information.
Without specific written authorization, we are permitted to use and disclose
your health care records for the purposes of treatment, payment and health care
operations.
- Treatment means providing, coordinating, or managing health care and
related services by one or more health care providers. Examples of treatment
would include crowns, fillings, teeth cleaning services, etc.
- Payment means such activities as obtaining reimbursement for
services, confirming coverage, billing or collection activities, and utilization
review. An example of this would be billing your dental plan for your dental
services.
- 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. An example
would include a periodic assessment of our documentation protocols, etc.
In addition, your confidential information may be used to remind you
of an appointment (by phone or mail) or provide you with information about
treatment options or other health-related services including release of
information to friends and family members that are directly involved in your
care or who assist in taking care of you. We will use and disclose your
protected when we are required to do so by federal, state or local law. We may
disclose your PROTECTED HEALTH INFORMATION to public health authorities that are
authorized by law to collect information, to a health oversight agency for
activities authorized by law included but not limited to: response to a court or
administrative order, if you are involved in a lawsuit or similar proceeding,
response to a discovery request, subpoena, or other lawful process by another
party involved in the dispute, but only if we have made an effort to inform you
of the request or to obtain an order protecting the information the party has
requested. We will release your PROTECTED HEALTH INFORMATION if requested by a
law enforcement official for any circumstance required by law. We may release
your PROTECTED HEALTH INFORMATION to a medical examiner or coroner to identify a
deceased individual or to identify the cause of death. If necessary, we also may
release information in order for funeral directors to perform their jobs. We may
release PROTECTED HEALTH INFORMATION to organizations that handle organ, eye or
tissue procurement or transplantation, including organ donation banks, as
necessary to facilitate organ or tissue donation and transplantation if you are
an organ donor. We may use and disclose your PROTECTED HEALTH INFORMATION when
necessary to reduce or prevent a serious threat to your health and safety or the
health and safety of another individual or the public. Under these
circumstances, we will only make disclosures to a person or organization able to
help prevent the threat. We may disclose your PROTECTED HEALTH INFORMATION if
you are a member of U.S. or foreign military forces (including veterans) and if
required by the appropriate authorities. We may disclose your PROTECTED HEALTH
INFORMATION to federal officials for intelligence and national security
activities authorized by law. We may disclose PROTECTED HEALTH INFORMATION to
federal officials in order to protect the President, other officials or foreign
heads of state, or to conduct investigations. We may disclose your PROTECTED
HEALTH INFORMATION to correctional institutions or law enforcement officials if
you are an inmate or under the custody of a law enforcement official. Disclosure
for these purposes would be necessary: (a) for the institution to provide health
care services to you, (b) for the safety and security of the institution, and/or
(c) to protect your health and safety or the health and safety of other
individuals or the public. We may release your PROTECTED HEALTH INFORMATION for
workers' compensation and similar programs.
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 honor and abide by that written request, except to the extent that we have
already taken actions relying on your authorization.
You have certain rights in regards to your PROTECTED HEALTH INFORMATION,
which you can exercise by presenting a written request to our Privacy Officer at
the practice address listed below:
- 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 request to receive confidential communications of PROTECTED
HEALTH INFORMATION from us by alternative means or at alternative locations.
- The right to access, inspect and copy your PROTECTED HEALTH INFORMATION.
- The right to request an amendment to your PROTECTED HEALTH INFORMATION.
- The right to receive an accounting of disclosures of PROTECTED HEALTH
INFORMATION outside of treatment, payment and health care operations.
- The right to obtain a paper copy of this notice from us upon request.
We are required by law to maintain the privacy of your PROTECTED
HEALTH INFORMATION and to provide you with notice of our legal duties and
privacy practices with respect to PROTECTED HEALTH INFORMATION.
We are required to abide by the terms of the Notice of Privacy Practices
currently in effect. We reserve the right to change the terms of our Notice of
Privacy Practices and to make the new notice provisions effective for all
PROTECTED HEALTH INFORMATION that we maintain. Revisions to our Notice of
Privacy Practices will be posted on the effective date and you may request a
written copy of the Revised Notice from this office.
You have the right to file a formal, written complaint with us at the address
below, or with the Department of Health & Human Services, Office of Civil
Rights, in the event you feel your privacy rights have been violated. We will
not retaliate against you for filing a complaint.
For more information about HIPAA or to file a complaint:
The U.S. Department of Health & Human Services
Office of Civil
Rights
200 Independence Avenue, S.W.
Washington, D.C.
20201
877-696-6775 (toll-free)
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