______________HIPAA Notice of Privacy Practices_____________
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSEDAND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
We will use and communicate your PROTECTED HEALTH INFORMATION (PHI) only for the purposes of providing your treatment, obtaining payment and conducting health care operations.
Your health information will not be used for other purposes unless we have asked for a voluntarily given written permission.
How your HEALTH INFORMATION may be used:
To Provide Treatment
We will use your HEALTH INFORMATION within our office to provide you with the best dental care possible. This may include administrative and clinical office procedures designed to optimize scheduling and coordination of care between
hygienist, dental assistant, dentist, and business office staff. In addition, we may share your health information with physicians, referring dentists, clinical and dental laboratories, pharmacies or other health care personnel providing your
treatment.
To Obtain Payment
We may include your health information with an invoice used to collect payment for treatment you receive in our office. We may do this with insurance forms filed for you in the mail or sent electronically. We will be sure to only work with companies that have a similar commitment to the security of your heath information.
To Conduct Health Care Operations
Your health information may be used during performance evaluations of our staff. Some of our best teaching opportunities use clinical situations, experiences by patients receiving care at our office. As a result, health information
may be included in training programs for students, interns, associates, and business or clinical employees. It is also possible that health information will be disclosed during audits by insurance companies or government appointed
agencies as part of their quality assurance and compliance reviews. Your health information may be reviewed during the routine processes of certification, licensing or credentialing activities.
In Patient Reminders
Because we believe regular care is very important to your oral and general health, we will remind you of a scheduled appointment or that it is time for you to contact us and make an appointment. Additionally, we may contact you to follow
up on your care and inform you of treatment options or services that may be of interest to you or your family. These communications are an important part of our philosophy of partnering with our patients to be sure they receive the best
preventative and restorative care that modern dentistry can provide. They may include postcards, folding postcards, letters, telephone reminders or electronic reminders such as email (unless you tell us that you do not want to receive
these reminders).
Abuse or Neglect
We will notify government authorities if we believe a patient is a victim of abuse, neglect or domestic violence. We will make the disclosure only when we are compelled by our ethical judgment, when we believe we are specifically required
or authorized by law or with the patient’s agreement.
Public Health and National Security
We may be required to disclose to Federal officials or military authorities health information necessary to complete an investigation related to public health or national security. Health information could be important when the government
believes that the general public’s safety could benefit or when the information could lead to the control or prevention of an epidemic or the understanding of new side effects of a drug treatment or medical device.
For Law Enforcement
As permitted or required by State or Federal law, we may disclose your health information to a law enforcement official for certain law enforcement purposes, including, under certain limited circumstances, if you are a victim of a crime or in
order to report a crime.
Family, Friends, and Caregivers
We may share your health information with those you tell us will be helping you with your home hygiene, treatment, medications, or payment. We will be sure to ask your permission first. In the case of an emergency, where you are unable
to tell us what you want, we will use our very best judgment when sharing your health information only when it will be important to those participating in providing your care.
Authorization to Use or Disclose Health Information
Other than is stated above or where Federal, State or Local law requires us, we will not disclose your health information other than with your written authorization. You may revoke that authorization in writing at any time.
Patients Rights
This new law is careful to describe that you have the following rights related to your health information:
Restrictions
You have the right to request restrictions on certain uses and disclosures of your health information. Our office will make every effort to honor reasonable restriction preferences from our patients.
Confidential Communications
You have the right to request that we communicate with you in a certain way. You may request that we only communicate your health information privately with no other family members present or through mailed communications that are sealed.
We will make every effort to honor your reasonable requests for confidential communications.
Inspect and Copy Your Health Information
You have the right to read, review, and copy your health information, including your complete chart, x-rays and billing records. If you would like a copy of your health information, please let us know. We may need to charge you a reasonable fee to duplicate and assemble your copy.
Amend Your Health Information
You have the right to ask us to update or modify your records if you believe your health information records are incorrect or incomplete. We will be happy to accommodate you as long as our office maintains this information. In order to
standardize our process, please provide us with your request in writing and describe your reason for the change. Your request may be denied if the health information record in question was not created by our office, is not part of our records or if the records containing your health information are determined to be accurate and complete.
Documentation of Health Information
You have the right to ask us for a description of how and where your health information was used by our office for any reason other than for treatment, payment or health operations. Our documentation procedures will enable us to provide information on health information usage from April 14, 2003 and forward. Please let us know the time period for which you are interested. Thank you for limiting your request to no more than six years at a time. We may need to charge you a reasonable fee for your request.
Request a Paper Copy of this Notice
You have the right to obtain a copy of this Notice of Privacy Practices directly from our office at any time. Stop by or give us a call and we will mail or email a copy to you. We are required by law to maintain the privacy of your health information
and to provide to you and your representative this Notice of our Privacy Practices. We are required to practice the policies and procedures described in this notice but we do reserve the right to change the terms of our Notice. If we change our
privacy practices we will be sure all of our patients receive a copy of the revised Notice. You have the right to express complaints to us or to the Secretary of Health and Human Services if you believe your privacy rights may have been
compromised. We encourage you to express any concerns you may have regarding the privacy of your information. Please let us know of your concerns or complaints in writing.
Patient Acknowledgement
Thank you very much for taking time to review how we are currently using your health information. If you have any questions, we want to hear from you. Please sign on the next page to acknowledge your receipt of this Notice of our Privacy Practices.
ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES
*YOU MAY REFUSE TO SIGN THIS ACKNOWLEDGEMENT*
I have read the HIPAA Notice of Privacy Practices. I understand how
my health information may be used and disclosed to third parties only for the purposes of providing treatment, obtaining payment and conducting health care operations. I understand that a paper copy of this notice may be provided to me at my request.