Shades Creek Dental is required by applicable federal and state law to maintain the privacy of your protected health information (PHI). We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your PHI. We must follow the privacy practices that are described in this Notice while it is in effect. This notice originally took effect on April 14, 2002, and was last updated January 2013. It 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 to our privacy practices and the new terms of our Notices effective for all PHI that we maintain, including PHI we created or received before we made the changes. Before we make any 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 DISCLOSURE OF PROTECTED HEALTH INFORMATION
We use and disclose PHI about you for treatment, payment, and health care operations. For example:
Treatment: We may use and disclose your PHI for treatment or disclose it to another dentist, physician, or other healthcare provider providing treatment to you. For example, dentists and/or physicians involved in your care will need information about your symptoms in order prescribe appropriate medications. Another example would be if your PHI may be sent to a specialist for continuation of your dental treatment.
Payment: We may use or disclose your PHI to obtain payment from third parties for the care you may receive from us. For example, we may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or Northwest Dental Group. Another example includes if Shades Creek Dental may have to send your PHI to collection agencies for payment of balances due to us. Health Care Operations: We may use and disclose your PHI for standard internal operations, including proper administration of records, evaluation of the quality of treatment and to assess the care and outcomes of your case and others like it. On Your Authorization: In addition to our use of your PHI for treatment, payment or healthcare operations, you may give us written authorization to use your PHI 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 PHI for any reason except those described in this Notice. To Your Family and Friends: We must disclose your PHI to you, as described in the Patient Rights section of this Notice. We may disclose your PHI 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 we have your written permission to do so. Persons Involved in Care: We may use or disclose PHI to notify or assist 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 the use or disclosure of your PHI, 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 PHI based on a determination using our professional judgment disclosing only PHI 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 PHI. Special Uses: We may use or disclose your PHI to provide you with appointment reminders (such as voicemail messages, postcards, answering machines and/or a person answering your telephone, text messages and e-mails). If we intend to send communications concerning treatment alternatives or other health-related products or services for which we receive compensation, or intend to contact individuals to raise funds for our facility, you have the right to be informed of such and to opt-out of receiving such communications. Marketing Health-Related Services: We will not use for PHI for marketing communications of disclosures that constitute a sale of PHI without your written authorization. Disaster Relief: We may use or disclose your PHI to a public or private entity authorized by law or by its charter to assist in disaster relief efforts. Public Benefit: We may use or disclose your medical information as authorized by law for the following purposes deemed to be in the public interest or benefit: as required by law; for public health activities, including disease and vital statistic reporting, child abuse reporting, FDA oversight, and to employers regarding work-related illness or injury; to report adult abuse, neglect or domestic violence; to health oversight agencies; in response to court and administrative orders and other lawful processes; to law enforcement officials pursuant to subpoenas and other lawful processes, concerning crime victims, suspicious deaths, crimes on our premises, reporting crimes in emergencies, and for purposes of identifying a suspect or other person; to coroners, medical examiners, and funeral directors; to an organ procurement organization; to avert a serious threat to health or safety; in connection with certain research activities; to the military and to federal officials for lawful intelligence, counterintelligence, and nation security activities; to correctional institutions regarding inmates, as authorized by state worker’s compensation laws; and for certain fundraising purposes.
Access: You have the right to look at or get copies of your PHI, with limited exceptions, including billing records. 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 PHI. You may request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you a reasonable cost-based fee that may include labor, copying costs, and postage. If you request an alternative format, we will charge a cost-based fee for providing your PHI in that format. If you prefer, we may – but are not required to – prepare a summary or an explanation of your PHI for a fee. Contact us
using the information listed at the end of this Notice for more information about fees. If this facility maintains PHI in an electronic health record, you have the right to obtain a copy of your electronic health record in an electronic format. Further, you may direct the facility to transmit your electronic health records to another entity or person. Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your PHI over the last three years. That list will not include disclosures for treatment, payment, health care operations, as authorized by you and for certain other activities unless this office uses electronic health records. If you request this accounting more than once in a twelve-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 more information about fees. If this facility uses or maintains electronic health records, you may request a list of instances where we have disclosed health information about you for reasons including disclosures made for treatment, payment or health care operations. Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your PHI. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). However, the facility must agree to a request for a restriction on the Disclosure of PHI to a Health Plan, or a Business Associate in a Health Plan, if the Disclosure is for the purposes of carrying out Payment of Health Care operations and is not otherwise required by Law; and the facility is paid out of pocket in full. In regards to other requests, restrictions will be granted on as follows; (a) it is the facility’s policy not to agree to any restrictions on uses or Disclosure for Treatment or Health Care Operations, except as stated above. The Privacy Officer must approve any exception in writing; (b) the facility is not allowed to grant requests to restrict any Disclosures required for public health, law enforcement, or to comply with any other laws or regulations. Any agreement we make to a request for additional restrictions must be in writing signed by a person authorized to make such an agreement on our behalf. Your request is not binding unless our agreement is in writing. Alternative Communications: You have the right to request that we communicate with you about your PHI by alternative means or to alternative locations. For example, you may ask that we only conduct communications pertaining to your PHI with you privately with no other family members present. You must make your request in writing. You must specify in your request the alternative means or location, and provide satisfactory explanation how you will handle payment under the alternative means or location you requested. Amendment: You have the right to request that we amend your PHI. Your request must be in writing, and it must explain why we should amend the information. We may deny your request if we did not create your health record, if the records you are requesting are not part of our records, if the PHI you wish to amend is not part of the PHI you or your representative are permitted to inspect or copy, or if, in the opinion of Northwest Dental Group, the records containing your PHI are accurate and complete.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us using the information listed at the end of this Notice. If you believe that we may have violated your privacy rights; we made a decision about access to your PHI incorrectly; our response to a request you made to amend or restrict the use or disclosure of your PHI was incorrect; or we should communicate with you by alternative means or alternative locations, you may contact us using the information listed below. You also may submit a written complaint to the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your PHI. 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.
IF YOU HAVE QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT:
Shades Creek Dental
1040 Broadway Street, Homewood, Alabama 35209