Dr. Michael R. LaFerla and Dr. Kyle Wilson , DDS, MS, PC NOTICE OF PRIVACY PRACTICES Date of Last Revision: 2-17-03 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. THIS NOTICE APPLIES TO ALL OF THE RECORDS OF YOUR CARE GENERATED BY THE PRACTICE OF MICHAEL R. LAFERLA, DDS, MS, PC, WHETHER MADE BY THE PRACTICE OR AN ASSOCIATED FACILITY. This notice describes our Practice’s policies, which extend to: • Any health care professional authorized to enter information into your chart (including physicians, assistants, etc.); • All areas of the Practice (front desk, administration, billing and collection, etc.); • All employees, staff and other personnel working for or with our Practice (janitors, computer support personnel, etc.) • Our business associates (labs, referring offices, physical therapists, dental supply companies, etc.). The Practice provides this Notice to comply with the Privacy Regulations issued by the Department of Health and Human Services in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). OUR THOUGHTS ABOUT YOUR PROTECTED HEALTH INFORMATION: We understand that your medical information is personal to you and are committed to protecting your information. As our patient, we create paper and electronic medical records about your health, our care for you, and the services and/or items we provide to you as our patient. We need this record to provide for your care and to comply with certain legal requirements. We are required by law to: • make sure that the protected health information about you is kept private; • provide you access to this Notice of Privacy Practices and your legal rights regarding your protected health information • follow the conditions of the Notice that is currently in effect. HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU The following categories describe ways we use and disclose protected health information that we have and share with others. Each category of uses or disclosures provides a general explanation and provides some examples of uses. Not every use or disclosure in a category is either listed or actually in place. The explanation is provided for your general information only. • Medical Treatment We use your medical information to provide current or prospective medical treatment or services and may disclose your medical information to doctors, nurses, technicians, medical students, or hospital personnel involved in your care. For example, a doctor to whom we refer you for further care may need your medical record (s), prescriptions, requests of lab work and x-rays. We may discuss your medical information with you to recommend possible treatment options or alternatives that may be of interest to you. We may disclose your medical information to others involved in your medical care after you leave the Practice; this may include your family members, personal representatives authorized by you or by a legal mandate (a guardian or person named to handle your medical decisions, should you become incompetent). • Payment We may disclose your medical information for services and procedures so they may be billed and collected from you, an insurance company, or any other third party payor. For example, we may need to give your health care information, about treatment you received to obtain payment or reimbursement for the care provided to you by us. We may also tell your health plan and/or referring physician about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment, to facilitate payment of a referring physician, or the like. • Health Care Operations We may use and disclose medical information about you so that we can run our Practice more efficiently and ensure our patients receive quality care. These uses may include reviewing our treatment and services to evaluate the performance of our staff, deciding what additional services to offer and where, deciding what services are not needed, and whether certain new treatments are effective. We may also disclose information to doctors, nurses, technicians, medical students, and other personnel for review and learning purposes. We may also combine the medical information we have with medical information from other Practices to compare how we are doing and see where we can make improvements in the care and services we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are. We may use or disclose information about you for internal or external utilization review and/or quality assurance, to business associates for helping us comply with our legal requirements, to auditors to verify records, to billing companies to aid us in this process, etc. We shall endeavor, at all times when business associates are used, to advise them of their continued obligation to maintain the privacy of your medical records. • Appointment and Patient Recall Reminders We use a computerized patient check-in system that displays your name and appointment time at the check-in desk. In case of computer problems, we may ask that you sign in writing at the Receptionists' Desk, a "Sign In" log on the day of your appointment. On the day of your appointment, we may call your name in the reception area to bring you to the treatment area. We may use and disclose medical information to contact you as a reminder that you have an appointment for medical care with the Practice or that you are due to receive periodic care from the Practice. This contact may be by phone, in writing, e-mail, or otherwise and may involve the leaving of an e-mail, a message on an answering machine, or otherwise which could (potentially) be received or intercepted by others. • Open Bay Treatment Area Since we have an open bay treatment area there may be information discussed with you that may be overheard by other patients. We will make every reasonable attempt to discuss your case information only where you can hear. We want to protect the privacy of all our patients equally and for that reason, we are restricting the access to the open bay treatment area to the patients only. The parent, siblings, or other visitors present with the patient are asked to wait in the reception area. We have found that parents in the open bay have the opportunity to hear information about patients other than their child and that may violate their privacy. The following exceptions are established to continue the line of communication: o The patient is making their initial or consultation appointment (parents are a vital part of these treatment visits). Since the initial and consultation treatment rooms are enclosed the privacy of our other patients is not jeopardized. o At the end of each appointment, you will be brought back to discuss the treatment completed today and schedule the next appointment. • Emergency Situations In addition, we may disclose medical information about you to an organization assisting in a disaster relief effort or in an emergency situation so that your family can be notified about your condition, status and location. • Research Under certain circumstances, we may use and disclose medical information about you for research purposes regarding medications, efficiency of treatment protocols and the like. All research projects are subject to an approval process, which evaluates a proposed research project and its use of medical information. Before we use or disclose medical information for research, the project will have been approved through this research approval process. We will obtain an Authorization from you before using or disclosing your individually identifiable health information unless the authorization requirement has been waived. If possible, we will make the information non-identifiable to a specific patient. If the information has been sufficiently de-identified, an authorization for the use or disclosure is not required. • Required By Law. We will disclose medical information about you when required to do so by federal, state or local law enforcement agencies. • To Avert a Serious Threat to Health or Safety. We may use and disclose medical information about you when necessary to prevent a serious threat either to your specific health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. • Workers' Compensation We may release your medical information for workers' compensation or similar programs that provide benefits for work-related injuries or illness. • Public Health Risks Law or public policy may require us to disclose medical information about you for public health activities. These activities generally include the following: • to prevent or control disease, injury or disability; • to report births and deaths; • to report child abuse or neglect; • to report reactions to medications or problems with products; • to notify people of recalls of products they may be using; • to notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; • to notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law. • Investigation and Government Activities We may disclose medical information to a local, state or federal agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the payor, the government and other regulatory agencies to monitor the health care system, government programs, and compliance with civil rights laws. • Lawsuits and Disputes If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. This is particularly true if you make your health an issue. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute. We shall attempt in these cases to tell you about the request so that you may obtain an order protecting the information requested if you so desire. We may use such information to defend ourselves, or any member of our Practice in any actual or threatened action. • Law Enforcement We may release medical information if asked to do so by a law enforcement official: • In response to a court order, subpoena, warrant, summons or similar process; • To identify or locate a suspect, fugitive, material witness, or missing person; • About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement; • About a death we believe may be the result of criminal conduct; • About criminal conduct at the Practice; and • In emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime. • Coroners, Medical Examiners and Funeral Directors We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients of the Practice to funeral directors as necessary to carry out their duties. • Inmates If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution. CHANGES TO THIS NOTICE We reserve the right to change this notice at any time. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we may receive from you in the future. We will post a copy of the current notice in the Practice. The notice will contain on the first page, in the top left-hand corner, the date of last revision. In addition, each time you visit the Practice for treatment or health care services you may request a copy of the current notice in effect. COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services. To file a complaint with the Practice, contact our HIPAA Compliance Officer, who will direct you on how to file an office complaint. All complaints must be submitted in writing, and all complaints shall be investigated, without repercussion to you. [The HIPAA Compliance Officer, Erma Hembree, can be reached at this number : 417-206-7770] You will not be penalized for filing a complaint. OTHER USES OF MEDICAL INFORMATION Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission, unless those uses can be reasonably inferred from the intended uses covered by our policy. If you have provided us with your permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you. PATIENT RIGHTS THIS SECTION DESCRIBES YOUR RIGHTS AND OUR OBLIGATIONS REGARDING THE USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION. You have the following rights regarding medical information we maintain about you: • Right to Inspect and Copy You have the right to inspect and copy medical information that may be used to make decisions about your care. This includes your own medical and billing records, but does not include psychotherapy notes. Upon proof of an appropriate legal relationship, records of others related to you or under your care (guardian or custodial) may also be disclosed. To inspect and copy your medical record, you must submit your request in writing to our Compliance Officer. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies (tapes, disks, etc.) associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that our Compliance Committee review the denial. Another licensed health care professional chosen by the Practice will review your request and the denial. The person conducting the review will not be the person who denied your request. We will comply with the outcome and recommendations from that review.