USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

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.

We are required by law to maintain the privacy of your health facts and to provide you with the notice of our legal duties and privacy practices.  We must follow the terms of the notice effective April 14, 2003.  We do reserve the right to change the terms.  If there is a change, we will provide you with a written, revised notice upon request.

 

As a client of ours, facts about you may be used and disclosed to other parties for treatment, payment and health care operations.  These uses and disclosures require your consent, and include, but are not limited to the following information:

• A release of information contained in financial and or medical records
• Diseases spread person to person
• Drug and or alcohol abuse
• Medical History
• Treatment in progress
• Any other related facts

We may release the above to:

1. Your insurance company or any other person who will pay your bill for services or who will process your bill for services in order for us to receive payment
2. Any person from a program or an insurance company, who performs billing, quality and risk management tasks, such as insurance auditors and state Risk Management
3. Your insurance company using electronic encrypted claims management
4. Any personal care facility where you live
5. Any other doctor providing your care
6. Family members and other people who are part of your plan for service
7. State and Federal agencies acting on behalf of programs such as Medicare or Medicaid
8. Other health care people to start treatment

We may contact you via telephone, postcard or other mailings to:

1. Provide appointment reminders
2. Discuss issues involving scheduling or payments on your account

 

We may use an electronic patient sign-in for:

1. The purpose of keeping track of patients that are being seen on a daily basis

 

We may take photographs to:

1. Use for decisions made in dental treatment
2. Posting within our offices for the purpose of showing the progression of treatment

We are allowed to use or disclose facts about you without consent in the following situations:

1. In emergency treatment situations, if we try to obtain consent as soon as possible after treatment
2. Where significant barriers to communication with you exist and we determine that the consent is clearly inferred from the situation
3. Where we are required by law to obtain treatment and we are unable to obtain consent
4. For certain public health activities, such as reporting injuries, death, diseases, etc.
5. Where the use or disclosure is required by law
6. Where we reasonably believe you are a victim of abuse, neglect or domestic violence
7. To coroners, medical examiners and funeral directors
8. For certain research purposes
9. For Workman’s Compensation purposes
10. For specialized government functions, including custodial situations

 

We are allowed to use or disclose facts about you without consent or authorization provided you are informed in advance and given the chance to agree to, restrict or forbid the disclosure in the following situations:

1. The use of a directory of people served by us (clinic schedules, patient schedules)
2. To a family member, friend or other person you choose, who may assist in your care or payment for care

YOUR RIGHTS

You have the right, subject to certain conditions, to:

1. Request restrictions on certain uses and disclosures of facts about you; however, we are not required to agree to the requested restrictions
2. Receive confidential communication by giving us another address
3. Inspect and receive a copy of protected health data by filling out our request form
4. Receive a list of disclosures made of your protected health data by filling out our request form
5. Amend protected health data by filling out our request form
6. Obtain a copy of this notice at any time

COMPLAINTS
 

You may complain to us and the Secretary of the U.S. Department of Health and Human Services if you believe that your privacy rights have been violated.  The complaint must be filed in writing with us and must state the specific incident(s) including the date, what happened and details of the incident.

 

For details about filing a complaint with us, contact:

            Office Manager

            202-C LaSalle Ave.

            Hasbrouck Heights, N.J. 07604

 

 

 

 

ACKNOWLEDGEMENT