NOTICE OF PRIVACY PRACTICES
THIS NOTICE OF PRIVACY PRACTICES (“NOTICE”) DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Effective April 16, 2018
This Notice of Privacy Practices identifies the general ways your protected health information can be used or disclosed. Protected health information is the individually identifiable personal health information found in your medical and billing records. This information is created or received by a health care provider, insurance company, or employer, and relates to your past, present, or future physical or mental health conditions or the payment for health care services. This information can be transmitted or maintained in any form by Dr. Wisdom Teeth.
This Notice describes your legal rights regarding your protected health information. It also informs you of the legal duties and privacy practices of Dr. Wisdom Teeth.
For the purpose of this Notice, the terms “you” or “your” refers to the patient who is the subject of the protected health information. The terms “we”, “our” or “us” refers to Dr. Wisdom Teeth.
OUR LEGAL DUTIES
We are required, by law, to keep your identifiable protected health information private; provide you with this Notice of our legal duties and privacy practices with respect to your protected health information; and follow the terms of the Notice as long as it is in effect. If we revise this Notice, we will follow the terms of the revised Notice, as long as it is in effect.
HOW WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION
The following information describes how we are permitted, or required by law, to use and disclose your protected health information. Not every use or disclosure in a category will be listed.
Treatment: We may use or disclose your protected health information to a physician, dentist, or other health care provider, in or outside of Dr. Wisdom Teeth, in order to provide care and treatment to you. An example of this includes communicating with your general dentist regarding extracting a tooth. We may contact you to provide appointment reminders and to provide you with information about health-related services provided by Dr. Wisdom Teeth, or treatment alternatives that may be of interest to you.
Payment: We may use or disclose your protected health information to obtain payment for services we provide to you. We may disclose your protected health information to another health care provider or entity. For example, we may need to provide your health plan with information about surgery you received so your health plan will pay Dr. Wisdom Teeth or reimburse you for the surgery. Dr. Wisdom Teeth also will tell your health plan about a treatment you are going to receive to obtain the health plan’s prior approval for this treatment or to determine whether your plan will cover the treatment.
Health Care Operations: We may use or disclose protected health information about you to support the programs and activities of Dr. Wisdom Teeth such as quality and service improvement; health care delivery review; regulatory compliance, staff performance evaluation; competence or qualification review of health care professionals; education and training of physicians and other health care providers; and business planning and development, business management and general administrative activities. We use this information to continuously improve the quality of care for all patients we serve. For example, we may combine protected health information about many patients to evaluate the need for new services or treatments. We may disclose information to doctors, nurses, and other students for educational purposes.
Additionally, we may share your protected health information with other health care providers and payors for certain of their business operations if the information is related to a relationship the provider or payor currently has or previously had with you, and if the provider or payor is required by federal law to protect the privacy of your protected health information.
Authorization for Other Disclosures: We will not use or disclose your protected health information, except as described throughout this document, unless you authorize us, in writing, to do so. You can revoke an authorization at any time, in writing. If you revoke an authorization, we will no longer use or disclose your protected health information for the purpose covered by the authorization. However, we are unable to take back any uses or disclosures already made with your authorization. Specific examples of uses or disclosures requiring authorization include: use of psychotherapy notes, marketing activities, the sale of your protected health information and most non-treatment uses and disclosures for which we are compensated.
Family and Friends: We may use or disclose your protected health information to notify or assist in notifying a family member, personal representative, or other person responsible for your care, of your location and general condition. We will also disclose protected health information to a family member, other relative, close personal friend, or any other person you identify, if the information is relevant to that person’s involvement with your care or payment for your care. You can prohibit disclosure of this information.
Future Communications: We may use or disclose your information to communicate with you via newsletters, mailings or other means regarding treatment options, health related information, disease-management programs, or other community based initiatives or activities in which Dr. Wisdom Teeth participates. If we receive any financial compensation for such communications (with limited exceptions), we will obtain your authorization prior to sending the communication and your authorization can be revoked at any time.
Public Health and Safety: We may use or disclose your protected health information, as authorized or required by local, state or federal law, for the following purposes deemed to be in the public interest or benefit:
• To report certain diseases and wounds, births and deaths, and suspected cases of abuse, neglect, or domestic violence;
• To help identify, locate, or report criminal suspects, crime victims, suspicious deaths, or criminal conduct on the premises of Dr. Wisdom Teeth;
• To respond to a court order, subpoena, or other judicial process;
• To assist federal disaster relief efforts;
• To enable product recalls, repairs, or replacements;
• To respond to an audit, inspection, or investigation by a health-related government agency;
• To assist in federal intelligence, counterintelligence, and national security issues;
• To facilitate organ and tissue donations;
• To assist coroners, medical examiners, and funeral directors;
• To respond to a request from a jail or prison regarding an inmate’s health or medical treatment;
• To respond to a request from your military command authority (if you are a member or veteran of the armed forces); To provide information to a workers’ compensation program.
Business Associates: There are some services provided at Dr. Wisdom Teeth through contracts with business associates. When these services are contracted, we may disclose your protected health information to the business associate so they can perform the job we have asked them to do. However, business associates are required by federal law to appropriately safeguard your information.
Confidential Communications: You have the right to request that we communicate protected health information to you by an alternate means or location other than your home address and telephone number. Your request must be made in writing to Dr. Wisdom Teeth’s Privacy Officer, and must specify how or where you wish to be contacted. We will try to accommodate your request for alternate communications. If you request an alternate means of communication, that request should also be communicated by you to each of your physicians.
Restrictions: You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the protected health information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that we not use or disclose information to a family member about a surgery you had. To request a restriction, you must make your request in writing to the Privacy Officer. We are not required to agree to your request. If we do agree, our agreement must be in writing, and we will comply with your request unless the information is needed to provide you emergency treatment.
Additionally, you have the right to request that we not use or disclose your protected health information to a health plan for purposes of payment or health care operations (not for treatment) if the information pertains solely to a health care item or service that has been paid for out-of-pocket and in full. Your request for restriction must be submitted in writing to Dr. Wisdom Teeth. In this case, Dr. Wisdom Teeth must honor your request. However, you should be aware that such restrictions may have unintended consequences, particularly if other providers need to know that information (such as a pharmacy filling a prescription). It will be your obligation to notify any such other providers of this restriction. Additionally, such a restriction may impact your health plan’s decision to pay for related care that you may not want to pay for out of pocket (and which would not be subject to the restriction).
Access: You have the right to review and obtain a copy of your health information, with certain exceptions. Usually, this includes medical and billing records, but does not include psychotherapy notes. Your request to review or obtain a copy of your health information must be in writing to our Privacy Officer. You will be charged fees as authorized by law. To the extent your information is held in an electronic health record, you may be able to receive the information in an electronic format.
Amendment: If you feel that the health information we have about you is incorrect or incomplete, you have the right to ask for an amendment of that information. You have the right to request an amendment for as long as the information is kept by or for us. Your request for an amendment must be made in writing to our listed Privacy Officer, and include a reason that supports your request. We do not have to honor your request but will advise you of our decision in writing.
Accounting of Disclosures: You have the right to receive a list of certain disclosures of your protected health information that we have made within the last six years. Your request for an accounting must be in writing to our listed Privacy Officer, and must state a time period for which you want an accounting. You may request one accounting free of charge within a 12-month period. A fee will be charged for additional lists within this same time period.
Breach Notification: In certain instances, you have the right to be notified in the event that we, or one of our Business Associates, discover an inappropriate use or disclosure of your protected health information. Notice of any such use or disclosure will be made in accordance with state and federal requirements.
Revisions of this Notice: We reserve the right to change this Notice, and the right to make the new provisions effective for all health information we currently maintain, as well as any information we receive in the future. If we make a major change to this Notice, the revised Notice will be posted in Dr. Wisdom Teeth’s place of business and on Dr. Wisdom Teeth’s web site. In addition, a paper copy of the revised Notice will be available upon request.
To Report a Complaint: If you believe your protected health information privacy rights have been violated, you can file a complaint with us by mail, at the address provided in this Notice. You may also file a complaint with the Secretary of the United States Department of Health and Human Services, Office of Civil Rights, by completing a Health Information Privacy Complaint Form (available at http://www.hhs.gov/ocr/privacy/hipaa/complaints/hipcomplaintform.pdf ) and sending it to the applicable OCR Regional Office listed on the form, or by calling 1-800-368-1019 for instructions and contact information. There will not be any penalty or retaliation against you for making a complaint to us or to the Department of Health and Human Services.
Copy of Notice: You have the right to a paper copy of this Notice. In addition, a copy of this Notice also may be obtained at our web site, www.drwisdomteethaz.com/hipaa
Contact Person: If you have any questions or need information regarding our legal duties and privacy practices, or how to exercise any of your protected health information rights listed in this Notice, please contact:
Dr Wisdom Teeth
287 E Hunt Hwy Ste #101
San Tan Valley, AZ 85143