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 law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured, protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 9/23/2013 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, display it clearly and prominently at our practice and make the 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 for different purposes, including treatment, payment, and healthcare operations. For each of these categories, we have provided a description and an example. Some information, such as HIV related information, genetic information, alcohol and/or substance abuse records, and mental health records may be entitled to special confidentiality protections applicable state or federal law. We will abide by these special protections as they pertain to applicable cases involving these types or records.
TREATMENT: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
PAYMENT: We may use and disclose your health information to obtain payment for treatment and services we provide to you. Payment activities include billing, collections, claims management, and determinations of eligibility and coverage to obtain payment from you, an insurance company, or a third party.
HEALTHCARE OPERATIONS: We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, conducting training programs, and licensing or credentialing activities.
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 authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosure 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. 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 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 person responsible 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 judgement disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgement 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. If a person has the authority by law to make healthcare decisions for you, we will treat that patient representative the same way we would treat you with respect to your health information.
MARKETING HEALTH-RELATED SERVICES: We will not use your health information for marketing communications without your written authorization.
DISASTER RELIEF: We may use or disclose your health information to assist in disaster relief efforts.
REQUIRED BY LAW: We may use or disclose your health information when we are required to do so by law.
PUBLIC HEALTH ACTIVITIES: We may disclose your health information for public health activities, including disclosures to: *Prevent or control disease, injury, or disability; *Report child abuse or neglect; *Report reactions to medications or problems with products or devices; *Notify a person of a recall, repair, or replacement of products or devices; *Notify a person who may have been exposed to a disease or condition; or *Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.
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.
SECRETARY OF HHS: We will disclose your health information to the Secretary of the U.S. Department of Health and Human Services when required to investigate or determine compliance with HIPPA.
WORKERS COMPENSATION: We may disclose your PHI to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
LAW ENFORCEMENT: We may disclose your PHI for law enforcement purposes as permitted by HIPPA, as required by law, or in response to a subpoena or court order.
HEALTH OVERSIGHT ACTIVITIES: We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and credentialing, as necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.
JUDICIAL AND ADMINISTRATIVE PROCEEDINGS: If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process instituted by someone else involved in the dispute, but only if efforts have been made, either by the requesting party or us, to tell you about the request or to obtain an order protecting the information requested.
RESEARCH: We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information.
CORONERS, MEDICAL EXAMINERS, AND FUNERAL DIRECTORS: We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors consistent with applicable law to enable them to carry out their duties.
FUNDRAISING: We may contact you to provide you with information about our sponsored activities, including fundraising programs, as permitted by applicable law. If you do not wish to receive such information from us, you may opt out of receiving the communications.
APPOINTMENT REMINDERS: We may use or disclose your health information to provide you with appointment reminders (such as voice mail messages, postcards, or letters).
OTHER USES AND DISCLOSURES OF PHI: Your authorization is required, with a few exceptions, for disclosure of psychotherapy notes, use or disclosure of PHI for marketing, and for the sale of PHI. We will also obtain your written authorization before using or disclosing your PHI for purposes other than those provided for in this Notice (or as otherwise permitted or required by law). You make revoke an authorization in writing at any time. Upon receipt of written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization.
PATIENT RIGHTS 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 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 us a letter to the address at the end of this Notice. If you request copies, we will charge you $0.95 for each page , $25 per hour for staff to copy your health information, and postage if you want copies mailed to you. If you request an alternative format, we will charge a costbased 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.) If you are denied a request for access, you have the right to have the denial reviewed in accordance with the requirements of applicable law.
DISCLOSURE ACCOUNTING: With the exception of certain disclosures, you have the right to receive an accounting of disclosures of your health information in accordance with applicable laws and regulations. To request an accounting of disclosures of your health information, you must submit your request in writing to the Privacy Official. 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 by submitting a written request to the Privacy Official. Your written request must include: what information you want to limit, whether you want to limit our use, disclosure, or both; and to whom you want the limits to apply. We are not required to agree to your request except in the case where the disclosure is to a health plan for the purposes of carrying out payments, or health care operations, and the information pertains solely to a health care item or service for which you or a person on your behalf (other than the health plan), has paid our practice in full.
ALTERNATIVE COMMUNICATION: You have the right to request that we communicate with you about your health information by alternative means or to alternate 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 of your request. However, if we are unable to contact you using the ways or locations you have requested we may contact you using the information we have.
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. If we agree to your request, we will amend your record(s) and notify you of such. If we deny your request for an amendment, we will provide you with a written explanation of why we denied it and explain your rights.
RIGHT TO NOTIFICATION OF BREACH: You will receive notifications of breaches of your unsecured protected health information as required by law.
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 written form.
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 and disclosure of your health information or to have us communicate with you by alternative means or at alternate locations, you may complain 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.
c/o Keith Kriegel, D.D.S.
8355 Walnut Hill Lane, Suite 240
Dallas, Texas 75231