HIPAA NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL/DENTAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
It describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations and for other purposes required or permitted by law. It also describes your rights to access and control your protected health information (PHI). Protected health information is information about you that may identify you and that relates to your past, present and future physical, dental or mental health or condition and related dental or health care services.
We may use or disclose your PHI to a physician or other healthcare provider providing treatment to you. For example, your PHI may be provided to a dentist to whom you have been referred to ensure that the dentist has the necessary information to diagnose or treat you
We may use and disclose your PHI to obtain payment for services we provide to you
We may use and disclose your PHI in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of a healthcare professional, evaluating practitioner and provider performance, conducting training programs, and accreditation, certification, licensing or credentialing activities.
We may use or disclose your PHI to provide you with appointment reminders (such as voicemail messages, postcards, or letters).
In addition to our use of your PHI for treatment, payment or healthcare operations, you may give us written authorization to use your 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.
Required by Law
We will use or disclose your PHI when we are required to do so by law. These situations include public health issues, communicable diseases, health oversight, abuse, neglect, Food and Drug Administration requirements, legal proceedings, law enforcement, coroners, funeral directors, and required uses such as disclosures relating to organ donation, research, criminal activity, military activity, national security, and workers’ compensation.
Access: You have the right to look at or get copies of your PHI. Your request must be in writing. We can charge you a reasonable cost-based fee for expenses such as copies and staff time.
You have the right to receive a list of instances in which we or our business associates disclosed your PHI for purposes, other than treatment, payment, healthcare operations and certain other activities.
You have the right to request that we place additional restrictions on our use or disclosure of your PHI. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
You have the right to request in writing that we communicate with you about your PHI by alternative means or to alternative locations.
You have the right to request in writing that we amend your PHI. We may deny your request under certain circumstances.
You have the right to receive a paper copy of this notice even if you agreed to accept it electronically
QUESTIONS AND COMPLAINTS
Please contact us for more information about our privacy practices or if you have questions or concerns
If you feel that we have violated your privacy rights please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number. You may also complain to the U. S. Department of Health and Human Services.
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.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.