NOTICE OF PRIVACY PRACTICES

This Notice describes what health information about may be used and disclosed as well as how you can get access to this information. Please review it carefully.

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. The Act gives you, the patient, significant new rights to understand and control how your information is used. HIPAA provides penalties for covered entities that misuse personal health information.



As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We may use and disclose your medical records for several purposes, including treatment, payment, defense of legal matters, to family and friends, and health care operations.



Treatment includes providing, coordinating, and/or managing health care related services by one or more health care providers. An example of this would include teeth cleaning services. Payment includes such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a claim for your visit to your insurance company for payment.

Healthcare Operations: include the business aspects of running our practice, such as quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review. We may also create and distribute de-identified health information by removing all references to individually identifiable information.

To Your Family and Friends: 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. Before we disclose your health information to these people, we will provide you with an opportunity to object to our use or disclosure. If you are not present, or in the event of your incapacity or an emergency, we will disclose your medical information based on our professional judgment of whether the disclosure would be in your best interest. We may 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. We may use or disclose information about you to notify or assist in notifying a person involved in your care, of your location and general condition.

In some limited situations, the law allows or requires us to use/disclose your health information without your permission. Not all of these situations will apply to use; some may never come up at our office at all. Such uses or disclosures are:

When a state of federal law mandates that certain health information be reported for a specific purpose;
For public health purposes, such as contagious disease reporting, investigation or surveillance, and notices to and from the federal Food and Drug Administration regarding drugs or medical devices; Disclosures to governmental authorities about victims of suspected abuse, neglect, or domestic violence;
Uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws;
Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
Disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else;
Disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations;
Uses or disclosures for health related research;
Uses and disclosures to prevent a serious threat to health or safety;
Uses or disclosures for specialized government functions, such as for the protection of the president or high-ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of a member of the foreign service;
Disclosures of de-identified information;
Disclosures relating to worker’s compensation programs;
Disclosures of a “limited data set” for research, public health, or healthcare operations;
Incidental disclosures that are an unavoidable by-product of permitted uses or disclosures; Disclosures to “business associations” who perform healthcare operations for our office and who commit to respect the privacy of your health information.

We may contact you to provide appointment reminders or information about treatment alternative or other health-related benefits and services that may be of interest to you. If you wish to be omitted from any mailings, please provide a written notice. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:


The right to request restriction on certain uses and disclosures of protected health information, including this related to disclosures to family members, other relatives, close personal friends, or any
other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.

The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
The right to inspect and copy your protected health information.
The right to receive an accounting of disclosures of protected health information. 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 provide you with notice of our legal duties and privacy practices with respect to protected health information.


This notice is effective as of January 29, 2016 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office. 




If you think that we have not properly respected the privacy of your health information or that your privacy protections have been violated, you have the right to file a written complaint to use or the U.S. Department of Health and Human Services, Office for Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.


For more information about HIPAA and/or to file a complain, please call or visit our office or contact: 
U.S. department of Health & Human Services, Office for Civil Rights:
200 Independence Avenue, S.W. Washington, D.C. 20201
Phone: (202) 619-0257
Toll Free: 1-877-696-6775


I have read and understand the following policies. All of my questions have been addressed and answered to my satisfaction.