This notice describes how your health
information may be used and disclosed, as well as how you can get
access to this information. Please review it carefully.
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 will remain in effect until we replace it. We
reserve 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. In the event we make
a material change in our privacy practices, we will change this
Notice and provide it to you 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 at the
office you are assigned to.
Uses and Disclosures of Health
Information
We use and disclose health information about you for treatment,
payment, and healthcare operations. For example:
Treatment: We may use or disclose your health information to
a dentist or other healthcare provider providing treatment to you
for: a) the provision, coordination, or management of health care
and related services by health care providers; (b) consultation
between health care providers relating to a patient; or (c) the
referral of a patient for health care from one health care provider
to another.
Payment: We may use and disclose
your health information to obtain payment for services we provide to
you. This may include: (a) billing and collection activities and
related data processing; (b) actions by a health plan or insurer to
obtain premiums or to determine or fulfill its responsibilities for
coverage and provision of benefits under its health plan or
insurance agreement, determinations of eligibility or coverage,
adjudication or subrogation of health benefit claims; (c) medical
necessity and appropriateness of care reviews, utilization review
activities; and (d) disclosure to consumer reporting agencies of
information relating to collection of premiums or reimbursement.
Healthcare Operations: We may use
and disclose your health information in connection with our
healthcare operations. Healthcare operations include things such as
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 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. Your revocation will not affect any use or disclosures
permitted by your authorization while 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.
Marketing Health Products or Services:
We will not use your health information for marketing communications
without your prior written authorization. We may provide you with
information regarding products or services that we offer related to
your health care needs. We will never sell your health information
without your prior authorization.
To You, 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 or, if you are not able to
agree, if it is necessary in our professional judgment.
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.
Required by Law: We may use or
disclose your health information when we are required to do so by
law, including judicial and administrative proceedings.
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 under certain circumstances.
Appointment Reminders and Treatment
Alternatives: We may use or disclose your health information
to provide you with appointment reminders (such as voicemail
messages, postcards, or letters) or information about treatment
alternatives or other health-related benefits and services that may
be of interest to you. If you have a preferred method of contact,
please let our scheduling coordinator know.
Patient
Rights
Access: You have the right to review 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 the 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 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.
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, where you have
provided an authorization and certain other activities, for the last
6 years, but not for disclosure made prior to 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 in writing that we communicate with you about
your health information by alternative means or to alternative
locations. 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 a Website or by electronic mail (e-mail), you are
entitled to receive this Notice in written form
