This Notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. The privacy of your health information is important to us.
This Notice describes how we may use and disclose your protected health information to provide treatment, obtain payment and conduct health care operations and for other purposes permitted or required by law. It also describes your rights concerning your protected health information. ”Protected health information” is information about you, including demographic information that may identify you and relates to your past, present or future physical or mental health or condition and related health care services.
We are required by law to follow the practices described in this Notice. We may change the terms of this Notice at any time. The new Notice will be effective for all protected health information we maintain at that time including health information we created or received before we made the changes.
You may obtain a copy of our Notice of Privacy Practices at any time by calling our office or requesting one at your next appointment.
Treatment: We will use and disclose your protected health information to provide, coordinate and manage health care and related services for you. For example, we will disclose information to a specialist to whom you have been referred to ensure the provider has enough information to diagnose and, if appropriate, treat you. We may also disclose information to a laboratory that becomes involved in your treatment at our request.
Payment: We may use and disclose your protected health information to obtain payment for services we provided to you. For example, we will send the necessary information to your dental insurance carrier(s) to obtain payment for the treatment provided.
Healthcare Operations: We will use and disclose your protected health information to conduct the business activities of this office. These activities include, but are not limited to, quality assessment and improvement activities, review of the performance and qualifications of employees, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
We will share your protected health information with business associates that perform specific functions for our practice such as billing. When a business arrangement of this type requires the use of your information, we will have a written contract with the third party to protect the privacy of your protected health information.
We will use a sign-in sheet at the registration desk where you will be asked to sign your name. We will also call you by name in the waiting room when we are ready to begin your treatment. We will leave messages on answering machines, on voicemail, or with family members reminding you of appointments. We will send postcards reminding you of certain appointments or the need to make certain appointments.
Others Involved in Your Health Care: We must disclose your protected health information to you as described in the Patient Rights section of this Notice. We may disclose your protected health information to a family member or other person to the extent necessary to help with your health care or with payment for your health care, but only if you agree. If we determine it is in your best interest based on our professional judgement or experience with common practices, we may allow another person to pick up filled prescriptions, medical supplies, x-rays or other forms of health information.
We may use or disclose protected health information to notify or help in notifying a family member, a personal representative or any other person responsible for your care of your location, your general condition or your death. If you are present before the use or disclosure of your protected health information, we will provide you with the opportunity to object to such uses or disclosures. Finally, we may use or disclose your protected health information to an authorized public or private entity to help in disaster relief efforts and to coordinate uses and disclosures to family members or others involved in your health care.
Emergencies: If you are incapacitated or in emergency circumstances, we may use or disclose your protected health information to treat you.
Uses and Disclosures of Protected Health Information Based upon Your Written Authorization: Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing, except to the extent that an action has already been taken based on the authorization.
We may use or disclose your protected health information in the following situations without your consent or authorization:
Required by Law or for Public Health Activities: We disclose your protected health information when required by federal, state or local law. Examples of such mandatory disclosures include notifying state or local health authorities regarding particular communicable diseases or providing protected health information to a governmental or regulatory agency with health care oversight responsibilities. If authorized by law, we may disclose your protected health information to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition. We may release protected health information to a coroner or medical examiner to assist in identifying a deceased individual or to determine the cause of death.
Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), under certain conditions in response to a subpoena, discovery request or other lawful process. We may disclose protected health information to any governmental agency or regulator with whom you have filed a complaint or as part of a regulatory agency examination.
Law Enforcement or Specific Government Functions: We may disclose protected health information in response to a request by a law enforcement official made through a court order, subpoena, warrant, summons or similar process. We may disclose protected health information about you to federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Threat to Health or Safety: We may disclose protected health information to avert a serious threat to someone’s health or safety. This includes reporting suspected abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information and will be made consistent with the requirements of applicable federal and state laws.
Workers’ Compensation: We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legally established programs.
Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.
Your rights with respect to your protected health information and how you may exercise those rights are outlined below:
You have a right to obtain a copy of or inspect your protected health information: Protected health information includes treatment records, billing records and any other records used by us to make decisions about your treatment. A reasonable cost-based fee will be charged for expenses such as staff time, copies and postage. Contact us as indicated at the end of this Notice to obtain information about our fees or if you have any questions about your access.
You have a right to request a restriction on the use and disclosure of your protected health information: You may ask us not to use or disclose some part of your protected health information for the purposes of treatment, payment or operations. You may also request that we not disclose some part of your information to family members and others who may be involved in your care or for notification purposes as otherwise described in this Notice. You may request a restriction by sending your request in writing to our Privacy Contact at our office’s address. Although we are not required to agree to the restriction, we will review the request and notify you of our decision. If accepted, we are legally obligated to abide by the restriction.
You have a right to request receipt of confidential communications by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Contact.
You may have the right to request an amendment to your protected health information. You may request that we amend protected health information about you. Your request must be in writing with an explanation as to why the information should be amended. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. It excludes disclosures for treatment, payment or healthcare operations as described in this Notice of Privacy Practices, to you, to family members or friends involved in your care, for notification purposes or as a result of an authorization signed by you. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003, for up to the previous six years. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations. If you request an accounting more than once in a 12-month period, we will charge you a reasonable cost-based fee for responding to the additional request.
You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.
If you have any questions, concerns or want more information about our privacy practices please contact us using the information below.
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, document the complaint and send it to the HIPAA Privacy Contact at the address noted below. We support your right to the privacy of your protected health information and we will not penalize you for filing a complaint.
This notice was published and becomes effective on March 1, 2003.
Richard F. Dest, DDS · Mark G. Halbedl, DMD · Jon Yura, DDS
A Charlotte North Carolina Dentist Office · (704) 547-1279
8305 University Executive Park Dr, Ste. 300 · Charlotte North Carolina 28262© copyright 2010 Tyson Steele Dental Marketing All Rights Reserved