Acknowledgement of Receipt of Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED ANDĀ HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The Health Insurance Portability & Accountability Act of 1996 (HIPAA) requires all health care records and otherĀ individually identifiable health information (protected health information) used or disclosed to us in any form, whetherĀ electronically, on paper, or orally, be kept confidential. This federal law gives you, the patient, significant new rights toĀ understand and control how your health information is used. HIPAA provides penalties for covered entities thatĀ misuse personal health information. As required by HIPAA, we have prepared this explanation of how we areĀ required to maintain the privacy of your health information and how we may use and disclose your health information.
- Without specific written authorization, we are permitted to use and disclose your health care records for the purposesĀ of treatment, payment and health care operations.
- Treatment means providing, coordinating, or managing health care and related services by one or moreĀ health care providers. Examples of treatment would include crowns, fillings, teeth cleaning services, etc.
- Payment means such activities as obtaining reimbursement for services, confirming coverage, billing orĀ collection activities, and utilization review. An example of this would be billing your dental plan for yourĀ dental services.Ā
- Health Care Operations include the business aspects of running our practice, such as conducting qualityĀ assessment and improvement activities, auditing functions, costĀ-management analysis, and customerĀ service. An example would include a periodic assessment of our documentation protocols, etc.Ā
In addition, your confidential information may be used to remind you of an appointment (by phone, text, email or mail) or provideĀ you with information about treatment options or other health- related services including release of information toĀ friends and family members that are directly involved in your care or who assist in taking care of you. We will use andĀ disclose your protected when we are required to do so by federal, state or local law. We may disclose yourĀ protected health information to public health authorities that are authorized by law to collect information,Ā to a health oversight agency for activities authorized by law included but not limited to: response to a court orĀ administrative order, if you are involved in a lawsuit or similar proceeding, response to a discovery request,Ā subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort toĀ inform you of the request or to obtain an order protecting the information the party has requested.Ā
We will releaseĀ your protected health information if requested by a law enforcement official for any circumstance requiredĀ by law. We may release your protected health informationto a medical examiner or coroner to identify aĀ deceased individual or to identify the cause of death. If necessary, we also may release information in order forĀ funeral directors to perform their jobs. We may releaseĀ protected health informationĀ to organizations thatĀ handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitateĀ organ or tissue donation and transplantation if you are an organ donor. We may use and disclose your protected health informationĀ when necessary to reduce or prevent a serious threat to your health and safety or theĀ health and safety of another individual or the public. Under these circumstances, we will only make disclosures to aĀ person or organization able to help prevent the threat.Ā
We may disclose your protected health informationĀ if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriateĀ authorities. We may disclose your protected health information to federal officials for intelligence andĀ national security activities authorized by law.Ā
WeĀ may disclose your protected health information to correctional institutions or law enforcementĀ HIPAA officials if you are an inmate or under the custody of a law enforcementĀ official. Disclosure for these purposes would be necessary:Ā Ā (a) for the institution to provide health care services toĀ you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health andĀ safety of other individuals or the public.Ā
We may release your protected health information for workers'Ā compensation and similar programs.
Any other uses and disclosures will be made only with your written authorization. You may revoke such authorizationĀ in writing and we are required to honor and abide by that written request, except to the extent that we have alreadyĀ taken actions relying on your authorization.
You have certain rights in regards to your protected health information, which you can exercise byĀ presenting a written request:
- The right to request restrictions on certain uses and disclosures of protected health information,Ā including those related to disclosures to family members, other relatives, close personal friends, or any otherĀ person identified by you. We are, however, not required to agree to a requested restriction. If we do agree toĀ a restriction, we must abide by it unless you agree in writing to remove it.
- The right to request to receive confidential communications of protected health information fromĀ us by alternative means or at alternative locations.
- The right to access, inspect and copy your protected health information.
- The right to request an amendment to your protected health information.
- The right to receive an accounting of disclosures of protected health information outside ofĀ treatment, payment and health care operations.
- The right to obtain a paper copy of this notice from us upon request.
We are required by law to maintain the privacy of your protected health information and to provide youĀ with notice of our legal duties and privacy practices.
We are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right toĀ change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for allĀ protected health information that we maintain. Revisions to our Notice of Privacy Practices will be postedĀ on the effective date and you may request a written copy of the Revised Notice from this office.Ā You have the right to file a formal, written complaint with us at the address below, or with the Department of Health &Ā Human Services, Office of Civil Rights, in the event you feel your privacy rights have been violated. We will notĀ retaliate against you for filing a complaint.
For more information about HIPAA or to file a complaint:
The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
877Ā-696-Ā6775 (tollĀfree)