THIS NOTICE DESCRIBES HOW MEDICAL INFORATMION ABOUT YOU MAY BE USED AND DISCLOSED ANDHOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The Health Insurance Portability & Accountability Act of 1996 (HIPPA) is a federal program that requires that 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. "HIPPAA" provides penalties for covered entities that misuse personal health information.
Asrequiredby "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.
We may use and disclose your medical records only for each of the following purposes: treatment, payment, and health care operations. Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include teeth cleaning services 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 visit 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 will not, however, use your medical information for marketing communications without your written consent. An example would be an internal quality assessment review.
We may also create and distribute de-identifiable 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 servicesthat 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 wearerequired to honor 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 can exercise by presenting a written request to the Privacy Officer: The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosuresof protected health information, including those related to disclosures of family members, other relatives, close personal friends, or any other person identified to you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we mustabide by it unless you agree in writing to remove it. The right to reasonable requests to receive confidential communications of protected health information from use by alternative means or
The right to inspect and copy your protected health information. We reserve the right to charge a cost-based fee duplicating and postage. 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.
We are required by law to maintain the privacy of your protect health information and to provide you with notice of our legal duties and privacy withrespect to protected health information. This notice is effective as of April 14, 2003 and we are required to abide by the terms of the practices of NoticePrivacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisioneffective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of PrivacyPractices from this office. You have recourse if you feel you privacy protections have been violated. You have the right to file a written complaint with our office or with the Department of Health and Human Services, Office of Civil Rights, about violation of the provisionsofthisnotice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.
For more information about our privacy practices, call or visit the office privacy officer, Dr. Brian Roberts.
I acknowledge that I received a copy of Brian B. Roberts D.D.S. Notice of Privacy Practices