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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.
Uses
and Disclosures
There are a number of situations where we may use or disclose
to other persons or entities your confidential medical information.
Certain uses and disclosures will require you to sign an Acknowledgement
that you received our Notice of Privacy Practices, including
treatment, payment and health care operations. Any use or
disclosure of your protected health information requires for
anything other than treatment, payment or health care operations
requires you to sign an Authorization. Certain disclosures
required by law or under emergency circumstances, may be made
without your Acknowledgement or Authorization. Under any circumstance,
we will use or disclose only the minimum amount of information
necessary from your medical records to accomplish the intended
purpose of the disclosure.
Use
and Disclosure without Patient Acknowledgement of this Notice
We
will attempt in good faith to obtain your signed Acknowledgement
that you received this Notice to use and disclose your confidential
medical information for the following purposes:
Treatment:
We will use your medical information to make decisions about
the provision, coordination or management of your health care,
including diagnosing your condition and determining the appropriate
treatment for that condition. It may also be necessary to
share your medical information with another health care provider
whom we need to consult with respect to your care. We may
also disclose certain information to a pharmacist for the
purpose of filling a prescription for you, to a physical therapist
to provide physical therapy under appropriate circumstances,
or to a facility or other providers should you require surgery
or other hospital care. These are only examples of uses and
disclosures of medical information for treatment purposes
that may or may not be necessary in your case.
Payment:
We may need to use or disclose information in your medical
record to obtain reimbursement from you or your health insurance
plan, or another insurer for our services rendered to you.
This may also include determinations of eligibility or coverage
under the appropriate health plan, pre-certification and pre-authorization
of services or review of services for purposes of reimbursement.
This information may also be used for billing, claims management
and collection purposes together with related health care
data processing through our system.
Operations:
Your medical records may be used in our business planning
and development operations, including improvement in our methods
of operation, and general administrative functions. We may
also use the information in our overall compliance planning,
medical review activities, and arranging for legal and auditing
functions.
Use
and Disclosure Without Acknowledgement or Authorization
There
are certain circumstances under which we may use or disclose
your medical information without first obtaining your Acknowledgement
or Authorization. Those circumstances generally involve public
health and oversight activities, law enforcement activities,
judicial and administrative proceedings and in the event of
death. Specifically, we are required to report to certain
agencies information concerning certain communicable diseases,
sexually transmitted diseases and HIV/AIDS status. We are
also required to report instances of suspected or documented
abuse, neglect or domestic violence. We are required to report
to appropriate agencies and law enforcement officials information
that you or another person are in immediate threat of danger
to your health or safety as a result of violent activity.
We must also provide medical record information when ordered
by a court of law to do so.
Authorization
for Use or Disclosure
Except
as outlined in the above sections, your medical information
will not be used or disclosed to any other person or entity
without your specific Authorization, which may be revoked
at any time. In particular, except to the extent disclosure
has been made to governmental entities required by law to
maintain the confidentiality of the information, information
will not be further disclosed to any other person or entity
with respect to information concerning mental health treatment,
drug and alcohol abuse, HIV/AIDS, or sexually transmitted
diseases which may be contained in your medical records. We
likewise will not disclose your medical record information
to an employer for purposes of making employment decisions,
to a liability insurer or attorney as a result of injuries
sustained in an automobile accident, or to educational authorities,
without your written authorization.
Additional
Uses and Disclosures
We may
contact you from time to time to provide appointment reminders
or information about treatment alternatives or other health-related
benefits and services that may be of interest to you.
Individual
Rights
You have certain rights with respect to your medical record
information, as follows:
- You
may request that we restrict the uses and disclosures of
your medical records information for treatment, payment
and operations, or restrictions involving your care or payment
related to that care. We are not required to agree to the
restriction; however, if we agree, we will comply with it,
except with respect to emergencies, disclosure of the information
to you, or if we are otherwise required by law to make a
full disclosure without restriction.
- You
have the right to request receipt of confidential communications
of your medical information by an alternative means or at
an alternative location. If you require such an accommodation,
you will be charged a fee for the accommodation and will
be required to specify the alternative address or method
of contact and how payment will be handled.
- You
have the right to inspect, copy and request amendment to
your medical records. Access to your medical records will
not include psychotherapy notes contained in them, or information
compiled in anticipation of or for use in a civil, criminal
or administrative action or proceeding or for which your
access is otherwise restricted by law. We will charge a
reasonable fee for providing a copy of your medical records,
or a summary of those records, at your request, which includes
the cost of copying, postage, or preparation of an explanation
or summary of the information.
- All
requests for inspection, copying and/or amending information
in your medical records must be made in writing and be addressed
to "Privacy Officer" at our address. We will respond
to your request in a timely fashion.
- You
have a limited right to receive an accounting of all disclosures
we make to other persons or entities of your medical records
information except for disclosures required for treatment,
payment and health care operations, disclosures that require
an Authorization, disclosures incidental to another permissible
use or disclosure, and otherwise as allowed by law. We will
not charge you for the first accounting in any 12-month
period; however, we will charge you a reasonable fee for
each subsequent request for an accounting within the same
12-month period.
- You
have the right to obtain a paper copy of this notice if
the notice was initially provided to you electronically,
and to take one home with you if you wish.
- All
requests related to your rights herein must be made in writing
and addressed to "Privacy Officer" at the address
noted below.
Our
Duties
We have the following duties with respect to the maintenance,
use and disclosure of your medical records:
- We
are required by law to maintain the privacy of the protected
health information in your medical records and to provide
you with this Notice of its legal duties and privacy practices
with respect to that information.
- We
are required to abide by the terms of this Notice currently
in effect.
- We
reserve the right to change the terms of this Notice at
any time, making the new provisions effective for all health
information and medical records we have and continue to
maintain. All changes in this Notice will be prominently
displayed and available at our office.
Complaints
You may file a written complaint to us or to the Secretary
of Health and Human Services if you believe your privacy rights
with respect to confidential information in your medical records
have been violated. All complaints must be in writing and
must be addressed to the Privacy Officer (in the case of a
complaint to us) or to the person designated by the U.S. Department
of Health and Human Services if we cannot resolve your concerns.
You will not be retaliated against for filing such a complaint.
More information is available about complaints on line at
the government's website: http://www.hhs.gov/ocr/hipaa.
Contact
Person
All questions concerning this Notice or requests made pursuant
to it should be addressed to:
Michael
J. Smith, DDS, FAGD
Reynoldsburg Family Dental
7457 East Main Street
Reynoldsburg, Ohio 43068
614-866-5518
Effective
Date
This Notice is effective April 14, 2003 and
applies to all protected health information contained in your
medical records maintained by us.
In
addition to our office Privacy Practices, we also have an
additional Privacy Policy for our
web site.
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