OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 04/14/03 and will remain In effect until we replace it.
We I'eserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.
USES AND DISCLOSURES OF HEALTH
INFORMATION
We use and disclose health information about
you for treatment, payment, and healthcare operations. For
example:
PATIENT RIGHTS
Access: You have the right to
look at or get copies of your health information, with limited
exceptions. You may request that we provide copies in a format
other than photocopies: We will use the format you request
unless we cannot practicably do so. (You must make a request in
writing to obtain access to your health information. You may
obtain a form to request access by using tile contact
information listed at the end of this Notice. We will charge
you a reasonable cost-based fee for expenses such as copies and
staff time. You may also request access by sending us a letter
to the address at the end of this Notice. If you request
copies, we may charge you for each page and for
staff time to locate and copy your health information, and
postage if you want the copies mailed to you. If you request an
alternative format, we will charge a cost-based fee for
providing your health information in that format. If you
prefer, we will prepare a summary or an explanation of your
health information for a fee. Contact us using the information
listed at the end of this Notice for a full explanation of our
fee structure.)
QUESTIONS AND COMPLAINTS
If you want more information about our privacy
practices or have questions or concerns, please contact us.
Treatment: We may use or disclose your health
information to a physician or other healthcare provider pro-
viding treatment to you.
Payment: We may use and disclose your health information to
obtain payment for services we provide to you.
Healthcare Operations: We may use and disclose your health
information in connection with our healthcare operations.
Healthcare operations include quality assessment and
improvement activities, reviewing the competence or
qualifications of healthcare professionals, evaluating
practitioner and provider performance, conducting training
programs, accreditation, certification, licensing or
credentialing activities.
Your Authorization: In addition to our use of your health
information for treatment, payment or healthcare operations,
you may give us writtert authorization to use you health
information or to disclose it to anyone for any purpose. If
you give us an authorization, you may revoke it in writing at
any time. Your revocation will not affect any use or
disclosures permitted by your authorization wllile it was in
effect. Unless you give us a written authorization, we cannot
use or disclose your health information for any reason except
those described in this Notice.
To Your Family and Friends:
We must disclose your health
information to you, as described in the Patient Rights section
of this Notice. We may disclose your health information to a
family member, friend or other person to the extent necessary
to help with your healthcare or with payment for your
healthcare, but only if you agree that we may do so.
Persons Involved In Care:
We may use or disclose health
information to notify, or assist in the notification of
(including identifying or locating) a family member, your
personal representative or another person responsible for your
care, of your location, your general condition, or death. If
you are present, then prior to use or disclosure of your health
information, we will provide you with an opportunity to object
to such uses or disclosures. In the event of your incapacity or
emergency circumstances, we will disclose health information
based on a determination using our professional judgment
disclosing only health information that is directly relevant to
the person's involvement in your healthcare. We will also use
our professional judgment and our experience with common
practice to make reasonable inferences of your best interest
in allowing a person to pick up filled prescriptions, medical
supplies, x-rays, or other similar forms of health
information.
Marketing Health-Related Services: We will not use your health
information for marketing communications without your written
authorization.
Required by Law: We may use or disclose your health
information when we are required to do so by law.
Abuse or Neglect:
We may disclose your health information to
appropriate authorities if we reasonably believe that you are a
possible victim of abuse, neglect, or domestic violence or the
possible victim of other crimes. We may disclose your health
information to the extent necessary to avert a serious threat
to your health or safety or the health or safety of
others.
National Security: We may disclose to military authorities the
health information of Armed Forces personnel under certain
circumstances. We may disclose to authorized federal officials
health information required for lawful intelligence,
counterintelligence, and other national security activities. We
may disclose to correctional institution or law enforcement
official having lawful custody of protected health information
of inmate or patient urider certain circumstances.
Appointment Reminders: We may use or disclose your health
information to provide you with appointment reminders (such as
voicemail messages, postcards, or letters).
Disclosure Accounting: You have the right to receive a
list of instances in which we or our business associates
disclosed your health information for purposes, other than
treatment, payment, healthcare operations and certain other
activities, for the last 6 years, but not before April 14,
2003. If you request this accounting more than once in a
12-month period, we may charge you a reasonable, cost-based fee
for responding to these additional requests.
Restriction: You have the right to request that we
place additional restrictions on our use or disclosure of your
health information. We are not required to agree to these
additional restrictions, but if we do, we will abide by our
agreement (except in an emergency).
Alternative Communication: You have the right to
request that we communicate with you about your health
information by alternative means or to alternative locations. (You
must make your request in writing.) Your request must specify
the alternative means or location, and provide satisfactory
explanation how payments will be handled under the alternative
means or location you request.
Amendment: You have the right to request that we amend
your health information. (Your request must be in writing, and
it must explain why the information should be amended.) We may
deny your request under certain circumstances.
Electronic Notice: If you receive this Notice on our Web site or by
electronic mail (e-mail), you are entitled to receive this
Notice in written form.
If you are concerned that we may have violated your privacy
rights, or you disagree with a decision we made about access to
your health information or in response to a request you made to
amend or restrict the use or disclosure of your health
information or to have us communicate with you by alternative
means or at alternative locations, you may complain to us using
the contact information listed at the end of this Notice. You
also may submit a written complaint to the U.S. Department of
Health and Human Services. We will provide you with the address
to file your complaint with the U.S. Department of Health and
Human Services upon request.
We support your right to the privacy of your health
information. We will not retaliate in any way if you choose to
file a complaint with us or with the U.S. Department of Health
and Human Services.
Contact
Officer:
Telephone:
Fax:
E-mail:
Address:
© 2002 American DenIal Association
All Rlghls Reserved
Reproducrion and use of this form by dentists and their staff
is permitted. Any other use, duplication or distribution of
this form by any other party requires the prior written approval
of the Amencan Dental Association.
This Form is educational only, does
not constitute legal advice, and covers only federal, not
state, law (August 14, 2002).