NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL/ORTHODONTIC INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
I.
Purpose of this Notice:
We are required by law to maintain the privacy of certain confidential health
care information, known as “Protected Health Information” or “PHI”, and to
provide you with a notice of our legal duties and privacy practices with respect
to your PHI. This Notice describes
your legal rights, advises you of our privacy practices, and lets you know how
we are permitted to use and disclose PHI about you.
We are also required to abide by the terms of the version of this Notice
currently in effect. In most situations we may use this information as described
in this Notice without your permission, but there are some situations where we
may use it only after we obtain your written authorization, if we are required
by law to do so.
II.
Uses and Disclosures of PHI:
We may use PHI for the purposes of treatment, payment, and health care
operations, in most cases without your written permission.
Examples of our use of your PHI are as follows:
A.
For treatment.
This includes such things as verbal and written information that we
obtain about you and use pertaining to your medical/orthodontic condition and
treatment provided to you by us and other health care providers.
It also includes information we give to other health care providers to
whom we transfer your care and treatment, and includes transfer of PHI via
telephone, facsimile and/or electronic mail, as well as providing health care
providers with a copy of the written record we create in the course of providing
you with treatment.
B.
For payment.
This includes any activities we must undertake in order to get reimbursed
for the services we provide to you, including such things as organizing your PHI
and submitting bills to insurance companies (either directly or through a third
party billing company), management of billed claims for services rendered,
medical necessity determinations and reviews, utilization review, and collection
of outstanding accounts.
C.
For health care operations.
This includes quality assurance activities, licensing, and training
programs to ensure that our personnel meet our standards of care and follow
established policies and procedures, obtaining legal and financial services,
conducting business planning, processing grievances and complaints, creating
reports that do not individually identify you for data collection purposes,
fund-raising, and certain marketing activities.
III. Use and
Disclosure of PHI Without Your Authorization.
We are permitted to use PHI without your written authorization, or
opportunity to object in certain situations, including:
A.
For our use in treating you or in obtaining payment for services provided to you
or in other health care operations;
B.
For the treatment activities of another health care provider;
C.
To another health care provider or entity for the payment activities of the
provider or entity that receives the information (such as another dentist or
insurance company);
D. To another health care provider for the health
care operation activities of the entity that receives the information as long as
the entity receiving the information has or has had a relationship with you and
the PHI pertains to that relationship;
E.
For health care fraud and abuse detection or for activities related to
compliance with the law;
F. To
a family member, other relative, or close personal friend or other individual
involved in your care if we obtain your verbal agreement to do so or if we give
you an opportunity to object to such a disclosure and you do not raise an
objection. We may also disclose
health information to your family, relatives, or friends if we infer from the
circumstances that you would not object. For example, we may assume you agree to
our disclosure of your personal health information to your spouse when your
spouse has called our office on your behalf.
In situations where you are not capable of objecting (because you are not
present or due to your incapacity or medical emergency), we may, in our
professional judgment, determine that a disclosure to your family member,
relative, or friend is in your best interest. In that situation, we will
disclose only health information relevant to that person’s involvement in your
care;
G.
We may use or disclose your PHI to provide you with appointment reminders (such
as voicemail messages, postcards, or letters);
H.
To a public health authority in certain situations (such as reporting a birth,
death or disease as required by law, as part of a public health investigation,
to report child or adult abuse or neglect or domestic violence, to report
adverse events such as product defects, or to notify a person about exposure to
a possible communicable disease as required by law);
I. For
health oversight activities including audits or government investigations,
inspections, disciplinary proceedings, and other administrative or judicial
actions undertaken by the government (or their contractors) by law to oversee
the health care system;
J.
For judicial and administrative proceedings as required by a court or
administrative order, or in some cases in response to a subpoena or other legal
process;
K.
For law enforcement activities in limited situations, such as when there is a
warrant for the request, or when the information is needed to locate a suspect
or stop a crime;
L. For
military, national defense and security and other special government functions;
M.
To avert a serious threat to the health and safety of a person or the public at
large;
N.
For workers’ compensation purposes, and in compliance with workers’
compensation laws;
O.
To coroners, medical examiners, and funeral directors for identifying a deceased
person, determining cause of death, or carrying on their duties as authorized by
law;
P.
If you are an organ donor, we may release health information to organizations
that handle organ procurement or organ, eye or tissue transplantation or to an
organ donation bank, as necessary to facilitate organ donation and
transplantation;
Q.
For research projects, but this will be subject to strict oversight and
approvals and health information will be released only when there is a minimal
risk to your privacy and adequate safeguards are in place in accordance with the
law;
R.
We may use or disclose health information about you in a way that does not
personally identify you or reveal who you are.
S.
Any other use or disclosure of PHI, other than those listed above will only be
made with your written authorization, (the authorization must specifically
identify the information we seek to use or disclose, as well as when and how we
seek to use or disclose it). You
may revoke your authorization at any time, in writing, except to the extent that
we have already used or disclosed medical/orthodontic information in reliance on
that authorization.
IV.
Patient Rights.
As a patient, you have a number of rights with respect to the protection
of your PHI, including:
A.
Right to access, copy or inspect PHI.
You have the right to inspect and copy most of the medical/orthodontic
information about you that we maintain.
We will normally provide you with access to this information within 30
days of your request. We may also
charge you a reasonable fee for you to copy any medical/orthodontic information
that you have the right to access.
In limited circumstances, we may deny you access to your medical/orthodontic
information, and you may appeal certain types of denials.
We have available forms to request access to your PHI and we will provide
a written response if we deny you access and let you know your appeal rights.
If you wish to inspect and copy your medical/orthodontic information, you
should contact the privacy officer listed at the end of this Notice.
B.
Right to amend PHI.
You have the right to ask us to amend written medical/orthodontic
information that we may have about you.
We will generally amend your information within 60 days of your request
and will notify you when we have amended the information.
We are permitted by law to deny your request to amend your medical
/orthodontic information only in certain circumstances, such as when we believe
the information you have asked us to amend is correct.
If you wish to request that we amend the medical/orthodontic information
that we have about you, you should contact the privacy officer listed at the end
of this Notice.
C.
Right to request an accounting of uses and disclosures of PHI.
You have the right to request an accounting from us of certain
disclosures of your medical/orthodontic information that we have made in the
last six (6) years prior to the date of your request.
We are not required to provide you with an accounting of information we
have used or disclosed for purposes of treatment, payment or health care
operations, or when we share your health information with our business
associates, such as our billing company.
We are not required to give you an accounting of our uses of protected
health information for which you have already given us written authorization.
If you wish to request an accounting of the medical/orthodontic
information about you that we have used or disclosed that is not exempted from
the accounting requirement, you should contact the privacy officer listed at the
end of this Notice.
D.
Right to request restrictions on uses and disclosures of PHI.
You have the right to request that we restrict how we use and disclose your
medical/orthodontic information that we have about you for treatment, payment or
health care operations, or to restrict the information that is provided to
family, friends and other individuals involved in your health care.
If you request a restriction and the information you asked us to restrict
is needed to provide you with emergency treatment, then we may use the PHI or
disclose the PHI to a health care provider to provide you with emergency
treatment. We are not required to agree to any restrictions you request;
however, any restrictions agreed to by us are binding.
E.
Internet, Electronic Mail, and the Right to Obtain Copy of Paper
Notice on Request.
If we maintain a web site, we will prominently post a copy of this Notice
on our web site and make the Notice available electronically through the web
site. If you allow us, we will
forward you this Notice by electronic mail instead of on paper. You have the
right to request a paper copy of the Notice at any time.
V.
Revisions to the Notice:
We reserve the right to change the terms of this Notice at any time, and
the changes will be effective immediately and will apply to all protected health
information that we maintain. Any
material changes to the Notice will be promptly posted in our facilities and
posted to our web site, if we maintain one.
You can obtain the latest version of this Notice by contacting the
Privacy Officer identified below.
VI.
Your Legal Rights and Complaints:
You also have the right to complain to us, or to the Secretary of the
United States Department of Health and Human Services, if you believe your
privacy rights have been violated. You will not be retaliated against in any way
for filing a complaint with us or to the government.
Should you have any questions, comments or complaints you may direct all
inquiries to the privacy officer listed at the end of this Notice.
If you have any questions or if you wish to file
a complaint or exercise any rights listed in this Notice, please contact:
PRIVACY OFFICER
Dr. Michael J. Koufos
Phone:
(219) 924-1440
Fax:
(219) 922-7258
Effective Date of the Notice:
59803.1
16,998-2