This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully!
With your consent, the practice is permitted by federal privacy laws to make use and disclosure of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination, test results, diagnosis, treatment, and applying for future care or treatment. It also includes billing documents for those services.
Example of use of your health information for treatment purposes:
A nurse obtains treatment information about you and records it in a health record. During the course of your treatment, the doctor determines a need to consult with another specialist in the area. The doctor will share the information with such specialist and obtain input.
Example of use of your health information for payment purposes:
We submit a request for payment to your dental insurance company. The dental insurance company requests information from us regarding dental care given. We will provide information to them about you and the care given.
Your Dental Health Information Rights
The dental records we maintain and billing records are the physical property of the practice. The information in it, however, belongs to you. You have a right to:
Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office. We are not required to grant the request but we will comply with any request granted;
Request that you be allowed to inspect and copy your dental record and billing record—you may exercise this right by delivering the request in writing to our office;
Appeal a denial of access to your protected dental information except in certain circumstances;
Request that your dental care record be amended to correct incomplete or incorrect information by delivering a written request to our office;
File a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected dental information;
Obtain an accounting of disclosures of your dental information as required to be maintained by law by delivering a written request to our office. An accounting will not include internal uses of information for treatment, payment or operations, disclosures made to you or made at your request, or disclosures made to family members or friends in the course of providing care;
Request that communication of your dental information be made by alternative means or at an alternative location by delivering the request in writing to our office; and, revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office.
If you want to exercise any of the above rights, please contact our office, in person or in writing, during normal hours. We will provide you with assistance on the steps to take to exercise your rights.
The practice is required to:
Maintain the privacy of your dental information as required by law;
Provide you with a notice of our duties and privacy practices as to the information we collect and maintain about you;
Abide by the terms of this Notice;
Notify you if we cannot accommodate a requested restriction or request; and accommodate your reasonable requests regarding methods to communicate health information with you.
We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices policy and to enact new provisions regarding the protected dental information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our "Notice" or by visiting our office and picking up a copy.
Other Disclosures and Uses Notification
Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.
Communication with Family
Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person's involvement in your care or in payment for such care if you do not object or in an emergency.
Food and Drug Administration (FDA)
We may disclose to the FDA your protected health information relating to adverse events with respect to products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.
If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.
As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Abuse & Neglect
We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.
If you are an inmate of a correctional institution, we may disclose to the institution, or its agents, your protected health information necessary for your health and the health and safety of other individuals.
We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement.
Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.
We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order.
Other uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization and you may revoke the authorization as previously provided.