ORAL SURGERY & DENTAL IMPLANT CENTER, INC.
NOTICE OF PRIVACY PRACTICES
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 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 04/14/2003 and changes made 05/20/2013 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
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:
FUNDRAISING AND MARKETING: We will not use or disclose your health information for marketing communications and/or for fundraising or to a fundraising organization.
TREATMENT: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you. This may be done via secure email or regular mail.
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 provide performance, conducting training programs, accreditation, and certification, licensing, or credentialing activities. We may send secure e-mails to referring physicians/dentists with x-rays, insurance information, and/or referrals.
YOUR AUTHORIZATION: In addition to our use of your health information for treatment, payment, or healthcare operations, 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. In the event a patient pays for service out of pocket in full, the patient has a right to request that our office not disclose health treatment information for that service to the health plan.
TO YOUR FAMILY AND FRIENDS: We must disclose health information to you, as described in the Patient Rights section of this Notice. We may 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.
PERSONS INVOLVED IN CARE: We 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 responsible person 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 incapacity or 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 prescriptions, medical supplies, x-rays, or other similar forms of health information.
REQUIRED BY LAW: We may use or disclose your health information when we are required to do so by law. Should a breach of unsecured personal health information (PHI) be made, we would contact you.
ABUSE OR NEGLECT: We may disclose your health information to appropriate authorities if we reasonable believe that you are a possible victim or abuse, neglect, or domestic violence or the possible victim or other crimes. We may disclose health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
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, or other national security activities. We may disclose to correctional institutions or law enforcement officials having lawful custody of protected health information of inmate or patient under certain circumstances.
APPOINTMENT REMINDERS: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, letters, postcards or e-mail).
ACCESS: You have the right to look at or receive 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. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending a letter to the contact information listed at the end of this Notice. If you request copies, we will charge you $0.50 for each page, for staff time to locate and copy your health information and postage if you want the copies mailed to you. If you request and 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 contact information listed at the end of this Notice.
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 months, 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 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 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 how payments will be handled under the alternative means or location your request.
AMENDMENT: You have the right to request that we amend your health information. Your request must be made in writing explaining why the information should be amended. We may deny your request under certain circumstances.
ELECTRONIC NOTICE: If you receive this Notice on our website or by e-mail, you are entitled to receive this Notice in written form. We currently do not have the capabilities of offering electronic copies of health information.
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 have violated your privacy rights, or you disagree with a decision we made about assess to your health information or in response to a request you made to amend or restrict the use or disclosure about 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 support your right to the privacy of your health information. We will not retaliate in any way if your choose to file a complaint with our office or with the U.S. Department of Health and Human Services.
Contact Officer: Valerie Mercer
Telephone: Middletown Office Phone Number 401-848-0070 Fax: 401-848-2225
E-mail: [email protected]
Address: 65 West Main Road, Middletown, RI 02842