ASSOCIATES IN DENTISTRY
NOTICE OF PRIVACY PRACTICES
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 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 health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect September 1, 2013, 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 make the new Notice available 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.
USES AND DISCLOSURES OF HEALTH INFORMATION
Your health information may be used and disclosed by our staff and others outside of our office who are involved in providing health care services to you.
Treatment: We may use or disclose your health information in order to provide, coordinate, or manage your health care and any related services. We may give information about you to physicians, dental technicians, dental assistants, office staff members or other personnel who are involved in taking care of you and your health. Our staff may share your information and disclose it to people who do not work in our office in order to coordinate your care, for example, your health information may be given to physicians who are involved in treating you or in providing assistance with your diagnosis and care.
Payment: We may use and disclose your health information to obtain payment for services we provide to you. Payment may be collected from you, an insurance company or another third party. For example, we may give information to your health plan about a service you are going to receive in order to obtain its approval, or to find out if your plan will pay for treatment.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. 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 activities.
To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may also 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, but only if you agree that we may do so.
Appointment reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).
Treatment Alternatives: We may also tell you about or recommend treatment options or alternatives that we think may be of interest to you.
Health-Related Products and Services: We may advise you about health-related products or services that we think may be of interest to you.
Please let us know if you do not wish to be contacted with appointment reminders or if you do not wish to receive communications about treatment alternatives or health-related products and services. If you advise us in writing that you do not wish to receive such communications, we will not disclose your information for these purposes.
Business Associates: We may share your health information with parties who perform various activities on our behalf and who are not our employees, referred to as “business associates.” We have written contracts with every business associate to protect the privacy of your health information.
Research: Under certain circumstances, we may use your health information for research. For example, a research project may involve comparing the health of patients who received one treatment to those who received another, for the same condition. Before we use or disclose health information for research, the project will go through a special approval process. Even without special approval, we may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes, as long as they do not remove or take a copy of any health information.
Disaster Relief: We may disclose your health information to disaster relief organizations that see your health information to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can do so.
We will not use or disclose your health information for any purpose other than for treatment, payment, or a health care operation without your specific, written Authorization. If you give us Authorization to use or disclose your health information, you may cancel it, in writing, at any time. If you cancel your Authorization, we will no longer use or disclose your health information for the reasons covered by your Authorization, but we cannot take back any uses or disclosures that we already made with your permission as stated in your Authorization.
We may use or disclose your health information without your permission for the following purposes, subject to all applicable legal requirements and limitations.
Persons Involved in Care: We may use or disclose your health information to notify, 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 conditions, 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 incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment discussing 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.
Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.
Sale of Protected Health Information: We will not make any disclosures that constitute a sale of your health information without your written authorization.
To Prevent a Serious Threat to Health and Safety: We may disclose health information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
Required by Law: We may use or disclose your health information when we are required to do so by federal, state, or local law.
Health Oversight Activities: We may disclose your health information for purposes of monitoring the healthcare systems, government programs, and compliance with civil rights laws.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are the possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may also disclose your health information to the extent necessary to avert a serious threat to your health, safety, or the health or safety of others.
Lawsuits and Disputes: We may disclose your health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons, or similar process, subject to all applicable legal requirements.
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 of protected health information of inmate or patient under certain circumstances.
Information not Personally Identifiable: We may use or disclose your health information in a way that does not personally identify or reveal who you are.
Worker’s Compensation: We may release health information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Data Breach Notification Purposes: We may use or disclose your health information to provide legally required notices of unauthorized access to or disclosure of your health information.
Coroners, Medical Examiners and Funeral Directors: We may release your health information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We also may release your health information to funeral directors as necessary for their duties.
You have the following rights regarding health information we keep about you.
Access: You 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 request in writing to obtain access to your health information. We have up to 30 days to make your health information available to you. You may obtain a form to request access by using the contact information listed at the end of the Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $.15 for each page, $15.00 per hour of staff time to locate and 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 fee structure.) We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state or federal needs-based benefit program.
Electronic Medical Records: If your health information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your health information in the form or format you request, if it is readily producible in such form or format. If the health information is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.
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 options and certain other activities, for the last 6 years, 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 additional requests.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to 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 your request. To request confidential communications, you must make your request in writing.
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: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in paper form.
Out-of-Pocket Payments: If you paid out-of-pocket (i.e., you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your health information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations, and we will honor that request.
CHANGES TO THIS NOTICE
We reserve the right to change this Notice at any time. The new notice will be effective for medical information we receive in the future. We will post a summary of the current notice in the office with the effective date in the top right corner. You are also entitled to a copy of the revised notice upon request. You can either call our office and request that a copy be sent to you in the mail or ask for one at the time of your next visit.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us. 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 request. 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 Human Services.
Contact Officer: Paula McKee E-Mail: PMckee@associatesindentistry.com
Telephone: 309-690-4500 Fax: 309-691-7296 Address: 9016 N. Allen Rd. Suite B, Peoria, IL 61615