Notice to patient: We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please check the box below to acknowledge receipt of the Notice. You may refuse to sign this acknowledgement.
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.
Our Legal Duty
We are required by
applicable federal and state law to maintain the privacy of your protected
health information. We are also required to give you this Notice about our
privacy practices, our legal duties, and your rights concerning your protected
health information. We must follow the privacy practices that are described in
this Notice while it is in effect. This Notice takes effect immediately and
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. Before we make a significant
change in our privacy practices, we will change this Notice and provide the new Notice at our practice location, and we
will distribute it upon request.
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 using the information
listed at the end of this notice.
addition to our use of your health information for the following purposes, 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.
Uses and Disclosures of Health Information
use and disclose health information about you without
authorization for the following purposes:
Treatment: We may use or disclose
your health information for your treatment. For example, we may disclose your
health information to a physician or other healthcare provider providing
treatment to you.
Payment: We may use and disclose
your health information to obtain payment for services we provide to you. For example, we may
send claims to your dental health plan containing certain health information.
Healthcare Operations: We may use and disclose
your health information in connection with our healthcare operations. For
example, healthcare operations include 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
To You or Your Personal
must disclose your health information to you, as described in the Patient
Rights section of this Notice. We may disclose your health information to your
personal representative, but only if you agree that we may do so.
Persons Involved In
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 absence or incapacity
or in 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.
Disaster Relief: We may use or disclose your health information
to assist in disaster relief efforts.
Services: We will not use your
health information for marketing communications without your written authorization.
Required by Law: We may use or disclose your health information
when we are required to do so by law.
Public Health and Public
Benefit: We may use or disclose your health information to
report abuse, neglect, or domestic violence; to report disease, injury, and
vital statistics; to report certain information to the Food and Drug
Administration (FDA); to alert someone who may be at risk of contracting or
spreading a disease; for health oversight activities; for certain judicial and
administrative proceedings; for certain law enforcement purposes; to avert a
serious threat to health or safety; and to comply with workers’ compensation or
Decedents: We may disclose health information about a decedent as authorized or
required by law.
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 the protected health information
of an inmate or patient under certain circumstances.
may use or disclose your health information to provide you with appointment
reminders (such as voicemail messages, postcards, or letters).
have the right to look at 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. You may also request access by sending us a
letter to the address at the end of this Notice. We will charge you a reasonable cost-based
fee for the cost of supplies and labor of copying. If you request copies, we will charge you for
each page, and per hour for staff time to copy your health information, and
postage if you want the copies mailed to you. 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
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, and certain other activities, for the last 6 years, but not before
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
Restriction: You have the right to
request that we place additional restrictions on our use or disclosure of your
health information. In most cases we are not required to agree to these
additional restrictions, but if we do, we will abide by our agreement (except
in certain circumstances where disclosure is required or permitted, such as an
emergency, for public health activities, or when disclosure is required by
law). We must comply with a request to restrict the disclosure of protected
health information to a health plan for purposes of carrying out payment or
health care operations (as defined by HIPAA) if the protected health information
pertains solely to a health care item or service for which we have been paid
out of pocket in full.
have the right to request that we communicate with you about your health
information by alternative means or at alternative locations. (You must make
your request in writing.) Your request must specify the alternative means or
location, and provide satisfactory explanation of 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: You may receive a paper copy of this notice upon request, even if you have
agreed to receive this notice electronically on our Web site or by electronic
Questions and Complaints
If you want more
information about our privacy practices or have questions or concerns, please
If you are concerned
that we may have violated your privacy rights, or you disagree with a decision
we made about access to your health information or in response to a request you
made to amend or restrict the use or disclosure of your health information or
to have us communicate with you by alternative means or at alternative
locations, you may complain to us using the contact information listed at the
end of this Notice. You also may submit a written complaint to the U.S.
Department of Health and Human Services. We will provide you with the address
to file your complaint with the U.S. Department of Health and Human Services upon
We support your right to
the privacy of your health information. We will not retaliate in any way if you
choose to file a complaint with us or with the U.S. Department of Health and