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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.
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. This Act gives
you, the patient, significant new rights to understand and
control how your health 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 only for each
of the following purposes: treatment, payment and health care
operations.
- Treatment means providing, coordinating,
or managing health care and related services by one or
more health care providers. An example of this would include
teeth cleaning services.
- Payment means such activities
as obtaining reimbursement for services, confirming coverage,
billing or collection activities, and utilization review.
An example of this would be sending a bill for your visit
to your insurance company for payment.
- Health care operations include
the business aspects of running our practice, such as
conducting 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.
We may contact you to provide
appointment reminders of information about treatment alternatives
or other health-related benefits and services that may be
of interest to you.
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 restrictions on
certain uses and disclosures of protected health information,
including those 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 amend your protected health
information.
- The right to receive an accounting
of disclosures of protected health information.
- The right to obtain and we have the
obligation to provide to you a paper copy of this notice
from us at your first service delivery date.
- The right to provide and we are obligated
to receive a written acknowledgement that you have received
a copy of our Notice of Privacy Practices.
We are required by law to maintain
the privacy of your protected health information and to provide
you with notice of our legal duties and privacy practices
with respect to protected health information.
This notice is effective as
of April 3, 2003, 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.
You have recourse if you feel
that your privacy protections have been violated. You have
the right to file a formal, written complaint with us at the
address below, or with the Department of Health & Human
Services, Office of 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.
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Please contact us
for more information:
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For more information
about HIPPA or to file a complaint:
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The U.S. Department
of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
(202) 619-0257
Toll Free: (877) 696-6775
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In addition to our office Privacy
Practices, we also have an additional Privacy
Policy for our web site.
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