HIPAA NOTICE OF PRIVACY PRACTICES

Our practice is required by law to maintain the privacy of your identifiable Protected Health Information and to provide individuals with notice of our legal duties and privacy practices with respect to such information.

This Notice will provide you with information regarding our privacy practices and applies to all Protected Health Information created and/or maintained by the practice, including any information that we receive from other health care providers. The Notice describes the ways in which the practice may use or disclose your Protected Health Information and also describes your rights and our obligations regarding any such uses or disclosures. The practice will abide by the terms of this Notice, including any future revisions that we may make to the Notice as required or authorized by law.

The following describes the ways we may use and disclose health information that identifies you (“Protected Health Information”). Except for the purposes described below, we will use and disclose Protected Health Information only with your written permission. You may revoke such permission at any time by writing to our practice Privacy Officer.

For Treatment. We may use and disclose Protected Health Information for your treatment and to provide you with treatment-related health care services. For example, we may disclose Protected Health Information to doctors, nurses, technicians, or other personnel, including people outside our office (for example, your pharmacy) who are involved in your medical care and need the information to provide you with medical care.

For Payment. We may use and disclose Protected Health Information so that we or others may bill and receive payment from you, an insurance company or a third party for the treatment and services you received. For example, we may give your health plan information about you so that they will pay for your treatment.

For Health Care Operations. We may use and disclose Protected Health Information for health care operations purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and to operate and manage our practice. For example, health care operations may include quality improvement activities and business management and administrative activities. We also may share information with other entities that have a relationship with you (for example, your health plan) for their health care operation activities.

Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services. We may use and disclose Protected Health Information to contact you to remind you that you have an appointment with us. We also may use and disclose Protected Health Information to tell you about treatment alternatives or health-related benefits and services that may be of interest to you.

Research. Under certain circumstances, we may use and disclose Protected Health Information for research purposes. For example, we may disclose your information to researchers preparing to conduct an investigation to help them look for patients with specific medical conditions.

As Required by Law. We will disclose Protected Health Information when required to do so by international, federal, state or local law.

To Avert a Serious Threat to Health or Safety. We may use and disclose Protected Health Information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.

Business Associates. We may disclose Protected Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect
the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract with the business associate.

Organ and Tissue Donation. If you are an organ donor, we may use or release Protected Health Information to organizations that handle organ procurement or other entities engaged in procurement, banking or transportation of organs, eyes or tissues to facilitate organ, eye or tissue donation and transplantation.

Military and Veterans. If you are a member of the military, we may release Protected Health Information as required by military command authorities.

Workers’ Compensation. We may release Protected Health Information for workers’ compensation or similar programs which provide benefits for work-related injuries or illness.

Public Health Risks. We may disclose Protected Health Information for public health activities. For example, we may disclose information to prevent or control disease, injury or disability or to notify you of a recall of a product you may be using.

Health Oversight Activities. We may disclose Protected Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, licensure and certification surveys. These activities are necessary for the government to monitor the health care system, government
programs, and compliance with civil rights laws.

Data Breach Notification Purposes. We may use or disclose your Protected Health Information to provide legally required notices of unauthorized access to or disclosure of your Protected Health Information.

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose Protected Health Information in response to a court or administrative order. We also may disclose Protected Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to
tell you about the request or to obtain an order protecting the information requested.

Law Enforcement. We may release Protected Health Information if asked by a law enforcement official if the information is: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very
limited circumstances, we are unable to obtain the person’s agreement; (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our premises; and  (6) in an emergency 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 Protected Health Information to a coroner, medical examiner, or funeral directors as necessary for their duties.

National Security and Intelligence Activities. We may release Protected Health Information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law.

Protective Services for the President and Others. We may disclose Protected Health Information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or for the conduct of special investigations.

Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Protected Health Information to the correctional institution or law enforcement official if 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.

Individuals Involved in Your Care or Payment for Your Care. Unless you object, we may disclose to a member of your family, a relative, a close personal friend or any other person you identify, your Protected Health Information that directly relates to that person’s involvement in your health care or payment. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.

Disaster Relief. We may disclose your Protected Health Information to disaster relief organizations that seek your Protected Health Information to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can do so.

The following uses and disclosures of your Protected Health Information will be made only with your written authorization:

1. Uses and disclosures of Protected Health Information for marketing purposes; and
2. Disclosures that constitute a sale of your Protected Health Information

Other uses and disclosures of Protected Health Information not covered by this Notice or the laws that apply to us will be made only with your written authorization. If you do give us an authorization, you may revoke it at any time by submitting a written revocation to our Privacy Officer and we will no longer disclose Protected Health Information under the authorization. But disclosure that we made in reliance on your authorization before you revoked it will not be affected by the revocation.

You have the following rights regarding Protected Health Information we have about you:

Right to Inspect and Copy. You have a right to inspect and copy Protected Health Information that may be used to make decisions about your care or payment for your care. This includes medical and billing records, other than psychotherapy notes. To inspect and copy this Protected Health Information, you must make your request, in writing, to the practice’s Compliance Officer. We have up to 30 days to make your Protected Health Information available to you and we may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request.

Right to an Electronic Copy of Electronic Medical Records. If your Protected Health Information is maintained in an electronic format, you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will provide access to your Protected Health Information in the form or format you request, if it is readily producible in such form or format. If the Protected Health Information is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.

Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured Protected Health Information.

Right to Request an Amendment. If you feel that Protected Health Information we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our practice. To request an amendment, you must make your request, in writing, to the practice’s Privacy Officer. In addition, you must provide us with a reason that supports your request. In certain cases, we may deny your request for amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with the decision and we may give a rebuttal to your statement.

Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we made of Protected Health Information for purposes other than treatment, payment and health care operations or for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to the Privacy
Officer.

Right to Request Restrictions. You have the right to request a restriction or limitation on the Protected Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Protected Health Information we disclose to someone involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, to the Privacy Officer. We are not required to agree to your request unless you are asking us to restrict the use and disclosure of your Protected Health Information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us “out-of-pocket” in full. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

Out-of-Pocket-Payments. If you paid out-of-pocket (or in other words, you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your Protected Health Information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.

Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. To request confidential communications, you must make your request, in writing, to the Privacy Officer. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests.

Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. You may obtain a copy of this Notice at our website, www.wrightsmilespediatricdentistry.com To obtain a paper copy of this Notice, please contact the Privacy Officer.

We reserve the right to change this Notice and make the new Notice apply to Protected Health Information we already have as well as any information we receive in the future. We will post a copy of our current Notice at our office and on our website (if we have one). The Notice will contain the effective date on the last page.

Thank you for choosing Wright Smiles. We are committed to providing your child with the best dental care. Your clear understanding of our Office Policy is important to our relationship.

• All necessary paperwork must be completed prior to being seen. These include patient charts, health history, consent forms and treatment plans.
• Payment is due in full the day of the appointment. If our estimate is more than what your insurance company originally estimated a refund will promptly be given. If the estimate is less, you will receive a billing statement by mail with your additional responsibility.




• A parent or legal guardian must accompany the patient to their first visit.




• We accept cash, check, Visa, Mastercard, Discover, and Care Credit.




• A 24-hour notice is required to change/cancel appointments to avoid a potential charge on your account.

**If you need to change your appointment date and/or time to avoid a $45.00 charge per hygiene appointment and $75.00 for treatment appointment that is scheduled. You may call and leave a message at our office 24 hours a day. **

• As the responsible party, it is your responsibility to provide complete and accurate information regarding your policy. This includes the personal information of the policy holder i.e., Name, date of birth, employer, social security number, member ID, network status, and claims address. If you are unable to provide these details at the time of the appointment, you can choose to pay out-of-pocket for the appointment or to reschedule for a later date.
• Your insurance policy is a contract between you and your insurance company. We are not a party to that Contract. If your insurance company has not paid within 60 days, the claim will be closed, and the balance will be transferred to you. Once you contact your insurance company regarding the claim, we will resubmit accordingly.
• We will also expect you to know your maximum’s, deductibles, and policy limitations prior to treatment. We cannot accept the responsibility of knowing all the details about your personal policy. Any Amount not paid by your insurance is your responsibility regardless of any estimation of benefits made by our office.

• Past due balances are subject to additional collection fees. Should you allow your account to be turned over to collections you will be responsible for all fees and expenses and will only be seen as a “self-pay” patient for future appointments the same guidelines apply if bankruptcy is filed.
• Payment is due in full the day of the appointment for all “self-pay” accounts.
• Our office does not get involved with 3rd party billing. The legal guardian that brings the child in for a visit is responsible for payment in full that day.

Thank you for understanding our Office Policy. Please let us know if you have any questions. "I have read and understand that regardless of my insurance status, I am ultimately responsible for the balance on my account."

If you have any questions about this Notice or if you believe we have not properly protected your privacy, or have violated your privacy rights, you may contact our Privacy Officer. You also may send a written complaint to the. The Privacy Officer can provide you with the appropriate address upon request. There will not be retaliation against those who choose to file
a complaint.

To act on any of the information provided in this Notice or for more information about our privacy practices, you may contact our Privacy Officer at:

Phone:937-885-2222:
Fax:937-885-9999
Email:frontdesk@wrightsmilespd.com
Mail:Wright Smiles Pediatric Dentistry, 50 Remick Blvd, Springboro, OH 45066