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Patient Privacy Policy
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 MEDICAL INFORMATION
IS IMPORTANT TO US.
Our Legal Duty
We are required by applicable federal and state laws to maintain
the privacy of your protected health information. We are also
required to give you this notice about our privacy practices,
our legal duties, and your rights concerning your protected
health information. We must follow the privacy practices that
are described in this notice while it is in effect. This notice
takes effect April 14, 2003, 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 that 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 protected health information
that we maintain, including medical information we created
or received before we made the changes.
You may request a copy of our notice (or any subsequent revised
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 Protected Health Information
We will use and disclose your protected health information
about you for treatment, payment, and health care operations.
Following are examples of the types of uses and disclosures
of your protected health care information that may occur.
These examples are not meant to be exhaustive, but to describe
the types of uses and disclosures that may be made by our
office.
Treatment: We will use and disclose your protected health
information to provide, coordinate or manage your health care
and any related services. This includes the coordination or
management of your health care with a third party. For example,
we would disclose your protected health information, as necessary,
to a home health agency that provides care to you. We will
also disclose protected health information to other physicians
who may be treating you. For example, your protected health
information may be provided to a physician to whom you have
been referred to ensure that the physician has the necessary
information to diagnose or treat you.
In addition, we may disclose your protected health information
from time to time to another physician or health care provider
(e.g., a specialist or laboratory) who, at the request of
your physician, becomes involved in your care by providing
assistance with your health care diagnosis or treatment to
your physician.
Payment: Your protected health information will be used,
as needed, to obtain payment for your health care services.
This may include certain activities that your health insurance
plan may undertake before it approves or pays for the health
care services we recommend for you, such as: making a determination
of eligibility or coverage for insurance benefits, reviewing
services provided to you for protected health necessity, and
undertaking utilization review activities. For example, obtaining
approval for a hospital stay may require that your relevant
protected health information be disclosed to the health plan
to obtain approval for the hospital admission.
Health Care Operations: We may use or disclose, as needed,
your protected health information in order to conduct certain
business and operational activities. These activities include,
but are not limited to, quality assessment activities, employee
review activities, training of students, licensing, and conducting
or arranging for other business activities.
For example, we may use a sign-in sheet at the registration
desk where you will be asked to sign your name. We may also
call you by name in the waiting room when your doctor is ready
to see you. We may use or disclose your protected health information,
as necessary, to contact you by telephone or mail to remind
you of your appointment.
We will share your protected health information with third
party "business associates" that perform various
activities (e.g., billing, transcription services) for the
practice. Whenever an arrangement between our office and a
business associate involves the use or disclosure of your
protected health information, we will have a written contract
that contains terms that will protect the privacy of your
protected health information.
We may use or disclose your protected health information,
as necessary, to provide you with information about treatment
alternatives or other health-related benefits and services
that may be of interest to you. We may also use and disclose
your protected health information for other marketing activities.
For example, your name and address may be used to send you
a newsletter about our practice and the services we offer.
We may also send you information about products or services
that we believe may be beneficial to you. You may contact
us to request that these materials not be sent to you.
Uses and Disclosures Based On Your Written Authorization:
Other uses and disclosures of your protected health information
will be made only with your authorization, unless otherwise
permitted or required by law as described below.
You may give us written authorization to use your protected
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. Without
your written authorization, we will not disclose your health
care information except as described in this notice.
Others Involved in Your Health Care: Unless you object, we
may disclose to a member of your family, a relative, a close
friend or any other person you identify, your protected health
information that directly relates to that person's involvement
in your health care. If you are unable to agree or object
to such a disclosure, we may disclose such information as
necessary if we determine that it is in your best interest
based on our professional judgment. We may use or disclose
protected health information to notify or assist in notifying
a family member, personal representative or any other person
that is responsible for your care of your location, general
condition or death.
Marketing: We may use your protected health information to
contact you with information about treatment alternatives
that may be of interest to you. We may disclose your protected
health information to a business associate to assist us in
these activities. Unless the information is provided to you
by a general newsletter or in person or is for products or
services of nominal value, you may opt out of receiving further
such information by telling us using the contact information
listed at the end of this notice.
Research; Death; Organ Donation: We may use or disclose your
protected health information for research purposes in limited
circumstances. We may disclose the protected health information
of a deceased person to a coroner, protected health examiner,
funeral director or organ procurement organization for certain
purposes.
Public Health and Safety: We may disclose your protected
health information to the extent necessary to avert a serious
and imminent threat to your health or safety, or the health
or safety of others. We may disclose your protected health
information to a government agency authorized to oversee the
health care system or government programs or its contractors,
and to public health authorities for public health purposes.
Health Oversight: We may disclose protected health information
to a health oversight agency for activities authorized by
law, such as audits, investigations and inspections. Oversight
agencies seeking this information include government agencies
that oversee the health care system, government benefit programs,
other government regulatory programs and civil rights laws.
Abuse or Neglect: We may disclose your protected health information
to a public health authority that is authorized by law to
receive reports of child abuse or neglect. In addition, we
may disclose your protected health information if we believe
that you have been a victim of abuse, neglect or domestic
violence to the governmental entity or agency authorized to
receive such information. In this case, the disclosure will
be made consistent with the requirements of applicable federal
and state laws.
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Food
and Drug Administration: We may disclose your protected health
information to a person or company required by the Food and
Drug Administration to report adverse events, product defects
or problems, biologic product deviations; to track products;
to enable product recalls; to make repairs or replacements;
or to conduct post marketing surveillance, as required.
Criminal Activity: Consistent with applicable federal and
state laws, we may disclose your protected health information,
if we believe that the use or disclosure is necessary to prevent
or lessen a serious and imminent threat to the health or safety
of a person or the public. We may also disclose protected
health information if it is necessary for law enforcement
authorities to identify or apprehend an individual.
Required by Law: We may use or disclose your protected health
information when we are required to do so by law. For example,
we must disclose your protected health information to the
U.S. Department of Health and Human Services upon request
for purposes of determining whether we are in compliance with
federal privacy laws. We may disclose your protected health
information when authorized by workers' compensation or similar
laws.
Process and Proceedings: We may disclose your protected health
information in response to a court or administrative order,
subpoena, discovery request or other lawful process, under
certain circumstances. Under limited circumstances, such as
a court order, warrant or grand jury subpoena, we may disclose
your protected health information to law enforcement officials.
Law Enforcement: We may disclose limited information to a
law enforcement official concerning the protected health information
of a suspect, fugitive, material witness, crime victim or
missing person. We may disclose the protected health information
of an inmate or other person in lawful custody to a law enforcement
official or correctional institution under certain circumstances.
We may disclose protected health information where necessary
to assist law enforcement officials to capture an individual
who has admitted to participation in a crime or has escaped
from lawful custody.
Patient Rights
Access: You have the right to look at or get copies of your
protected health information, with limited exceptions. You
must make a request in writing to the contact person listed
herein to obtain access to your protected health information.
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 $25.00 for each page or $10.00 per hour
to locate and copy your protected health information, and
postage if you want the copies mailed to you. If you prefer,
we will prepare a summary or an explanation of your protected
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.
Accounting of Disclosures: You have the right to receive
a list of instances in which we or our business associates
disclosed your protected health information for purposes other
than treatment, payment, health care operations and certain
other activities after April 14, 2003. After April 14, 2009,
the accounting will be provided for the past six (6) years.
We will provide you with the date on which we made the disclosure,
the name of the person or entity to whom we disclosed your
protected health information, a description of the protected
health information we disclosed, the reason for the disclosure,
and certain other information. If you request this list more
than once in a 12-month period, we may charge you a reasonable,
cost-based fee for responding to these additional requests.
Contact us using the information listed at the end of this
notice for a full explanation of our fee structure.
Restriction Requests: You have the right to request that
we place additional restrictions on our use or disclosure
of your protected 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). Any
agreement we may make to a request for additional restrictions
must be in writing signed by a person authorized to make such
an agreement on our behalf. We will not be bound unless our
agreement is so memorialized in writing.
Confidential Communication: You have the right to request
that we communicate with you in confidence about your protected
health information by alternative means or to an alternative
location. You must make your request in writing. We must accommodate
your request if it is reasonable, specifies the alternative
means or location, and continues to permit us to bill and
collect payment from you.
Amendment: You have the right to request that we amend your
protected health information. Your request must be in writing,
and it must explain why the information should be amended.
We may deny your request if we did not create the information
you want amended or for certain other reasons. If we deny
your request, we will provide you a written explanation. You
may respond with a statement of disagreement to be appended
to the information you wanted amended. If we accept your request
to amend the information, we will make reasonable efforts
to inform others, including people or entities you name, of
the amendment and to include the changes in any future disclosures
of that information.
Electronic Notice: If you receive this notice on our website
or by electronic mail (e-mail), you are entitled to receive
this notice in written form. Please contact us using the information
listed at the end of this notice to obtain this notice in
written form.
Questions and Complaints
If you want more information about our privacy practices or
have questions or concerns, please contact us using the information
below. If you believe that we may have violated your privacy
rights, or you disagree with a decision we made about access
to your protected health information or in response to a request
you made, you may complain to us using the contact information
below. 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 protect the privacy of your protected
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
Website Privacy Policy:
www.tustindentalcenter.com does not collect any unique information
about you (such as your name, address, phone, email address,
etc.) except when you specifically and knowingly provide such
info. www.tustindentalcenter.com notes and saves information such
as time of day, browser type, browser language, and IP address
with each query. That information is used to verify our records
and to provide more relevant services to users. We respects
and protects the privacy of the individuals that visit our
website. Individually identifiable information about you is
not willfully disclosed to any third party without first receiving
your permission...
www.tustindentalcenter.com reserves the right to modify this
privacy notice from time to time, by posting a prominent announcement
on this page.
We encourage you to periodically review this privacy statement
to stay informed about how we protect the personal information
we collect. |
