HIPAA Notice of Privacy Practices
Effective Date: September 1st, 2013
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.
We are required by law
privacy of protected health information
Give you this
notice of our legal duties and privacy practices regarding health information
Follow the terms
of our notice that is currently in effect
For Treatment. We may use and disclose Health
Information for your treatment and to provide you with treatment-related health
care services. For example, we may
disclose Health Information to doctors, nurses, technicians, or other
personnel, including people outside our office, who are involved in your medical
care and need the information to provide you with medical care.
For Payment. We may use and disclose Health
Information so that we or others may bill and receive payment from you, an
insurance company or a third party for the treatment and services you
received. For example, we may give your
health plan information about you so that they will pay for your
For Health Care Operations. We may use
and disclose Health Information for health care operations purposes. These uses and disclosures are necessary to
make sure that all of our patients receive quality care and to operate and
manage our office. We also may share information with other entities that have a
relationship with you (for example, your health plan) for their health care
Appointment Reminders, Treatment Alternatives and
Health Related Benefits and Services. We may use and disclose Health
Information to contact you to remind you that you have an appointment with
us. We also may use and disclose Health
Information to tell you about treatment alternatives or health-related benefits
and services that may be of interest to you.
Individuals Involved in Your Care or Payment for Your
Care. When appropriate, we may share Health
Information with a person who is involved in your medical care or payment for
your care, such as your family or a close friend. We also may notify your family about your
location or general condition or disclose such information to an entity
assisting in a disaster relief effort.
Research. Under certain circumstances, we may use and
disclose Health Information for research.
For example, a research project may involve comparing the health of
patients who received one treatment to those who received another, for the same
condition. Before we use or disclose
Health Information for research, the project will go through a special approval
process. Even without special approval,
we may permit researchers to look at records to help them identify patients who
may be included in their research project or for other similar purposes, as
long as they do not remove or take a copy of any Health Information.
As Required by Law. We will
disclose Health Information when required to do so by international, federal,
state or local law.
To Avert a Serious Threat to Health or Safety. We may use
and disclose Health Information when necessary to prevent a serious threat to
your health and safety or the health and safety of the public or another
person. Disclosures, however, will be made
only to someone who may be able to help prevent the threat.
Business Associates. We may
disclose Health Information to our business associates that perform functions
on our behalf or provide us with services if the information is necessary for
such functions or services. For example,
we may use another company to perform billing services on our behalf. All of our business associates are obligated
to protect the privacy of your information and are not allowed to use or
disclose any information other than as specified in our contract.
Organ and Tissue Donation. If you are
an organ donor, we may use or release Health Information to organizations that
handle organ procurement or other entities engaged in procurement, banking or
transportation of organs, eyes or tissues to facilitate organ, eye or tissue
donation and transplantation.
Military and Veterans. If you are a
member of the armed forces, we may release Health Information as required by
military command authorities. We also
may release Health Information to the appropriate foreign military authority if
you are a member of a foreign military.
Workers’ Compensation. We may
release Health Information for workers’ compensation or similar programs. These programs provide benefits for
work-related injuries or illness.
Public Health Risks. We may
disclose Health Information for public health activities. These activities generally include
disclosures to prevent or control disease, injury or disability; report births
and deaths; report child abuse or neglect; report reactions to medications or
problems with products; notify people of recalls of products they may be using;
a person who may have been exposed to a disease or may be at risk for
contracting or spreading a disease or condition; and the appropriate government
authority if we believe a patient has been the victim of abuse, neglect or
domestic violence. We will only make
this disclosure if you agree or when required or authorized by law.
Health Oversight Activities. We may
disclose Health Information to a health oversight agency for activities
authorized by law. These oversight
activities include, for example, audits, investigations, inspections, and
licensure. These activities are
necessary for the government to monitor the health care system, government
programs, and compliance with civil rights laws.
Data Breach Notification Purposes. We may use or
disclose your Protected Health Information to provide legally required notices
of unauthorized access to or disclosure of your health information.
Lawsuits and Disputes. If you are
involved in a lawsuit or a dispute, we may disclose Health Information in
response to a court or administrative order.
We also may disclose Health Information in response to a subpoena,
discovery request, or other lawful process by someone else involved in the
dispute, but only if efforts have been made to tell you about the request or to
obtain an order protecting the information requested.
Law Enforcement. We may release Health
Information if asked by a law enforcement official if the information is: (1)
in response to a court order, subpoena, warrant, summons or similar process;
(2) limited information to identify or locate a suspect, fugitive, material
witness, or missing person; (3) about the victim of a crime even if, under
certain very limited circumstances, we are unable to obtain the person’s
agreement; (4) about a death we believe may be the result of criminal conduct;
(5) about criminal conduct on our premises; and (6) in an emergency to report a
crime, the location of the crime or victims, or the identity, description or
location of the person who committed the crime.
Coroners, Medical Examiners and Funeral Directors. We may
release Health Information to a coroner or medical examiner. This may be necessary, for example, to
identify a deceased person or determine the cause of death. We also may release Health Information to
funeral directors as necessary for their duties.
National Security and Intelligence Activities. We may
release Health Information to authorized federal officials for intelligence,
counter-intelligence, and other national security activities authorized by
Protective Services for the President and Others. We may
disclose Health Information to authorized federal officials so they may provide
protection to the President, other authorized persons or foreign heads of state
or to conduct special investigations.
Inmates or Individuals in Custody. If you are
an inmate of a correctional institution or under the custody of a law
enforcement official, we may release Health Information to the correctional
institution or law enforcement official.
This release would be if necessary: (1) for the institution to provide
you with health care; (2) to protect your health and safety or the health and
safety of others; or (3) the safety and security of the correctional
USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN
OPPORTUNITY TO OBJECT AND OPT
Individuals Involved in Your Care or Payment for Your
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.
Disaster Relief. We may disclose
your Protected Health Information to disaster relief organizations that seek
your Protected Health Information to coordinate your care, or notify family and
friends of your location or condition in a disaster. We will provide you with an opportunity to
agree or object to such a disclosure whenever we practically can do so.
YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND
The following uses and disclosures of your Protected
Health Information will be made only with your written authorization:
1. Uses and
disclosures of Protected Health Information for marketing purposes; and
that constitute a sale of your Protected Health Information
Other uses and disclosures of Protected Health
Information not covered by this Notice or the laws that apply to us will be
made only with your written authorization.
If you do give us an authorization, you may revoke it at any time by
submitting a written revocation to our Privacy Officer and we will no longer
disclose Protected Health Information under the authorization. But disclosure that we made in reliance on
your authorization before you revoked it will not be affected by the
You have the following rights regarding Health
Information we have about you:
Right to Inspect and Copy. You have a
right to inspect and copy Health Information that may be used to make decisions
about your care or payment for your care.
This includes medical and billing records, other than psychotherapy
notes. To inspect and copy this Health
Information, you must make your request, in writing, to Soddy Daisy Smiles ATTN
Wanda Thompson. We have up to 30 days to
make your Protected Health Information available to you and we may charge you a
reasonable fee for the costs of copying, mailing or other supplies associated
with your request. We may not charge you
a fee if you need the information for a claim for benefits under the Social
Security Act or any other state of federal needs-based benefit program. We may deny your request in certain limited
circumstances. If we do deny your
request, you have the right to have the denial reviewed by a licensed healthcare
professional who was not directly involved in the denial of your request, and
we will comply with the outcome of the review.
Right to an Electronic Copy of Electronic Medical
Records. If your Protected
Health Information is maintained in an electronic format (known as an
electronic medical record or an electronic health record), you have the right
to request that an electronic copy of your record be given to you or
transmitted to another individual or entity.
We will make every effort to provide access to your Protected Health
Information in the form or format you request, if it is readily producible in
such form or format. If the Protected
Health Information is not readily producible in the form or format you request
your record will be provided in either our standard electronic format or if you
do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based
fee for the labor associated with transmitting the electronic medical record.
Right to Get Notice of a Breach. You have the
right to be notified upon a breach of any of your unsecured Protected Health
Right to Amend. If you feel that Health
Information we have is incorrect or incomplete, you may ask us to amend the
information. You have the right to
request an amendment for as long as the information is kept by or for our
office. To request an amendment, you
must make your request, in writing, to Soddy Daisy Smiles ATTN Wanda Thompson.
Right to an Accounting of Disclosures. You have the
right to request a list of certain disclosures we made of Health Information
for purposes other than treatment, payment and health care operations or for
which you provided written authorization.
To request an accounting of disclosures, you must make your request, in
writing, to Soddy Daisy Smiles ATTN Wanda Thompson.
Right to Request Restrictions. You have the
right to request a restriction or limitation on the Health Information we use
or disclose for treatment, payment, or health care operations. You also have the right to request a limit on
the Health Information we disclose to someone involved in your care or the
payment for your care, like a family member or friend. For example, you could ask that we not share
information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request,
in writing, to Soddy Daisy Smiles ATTN Wanda Thompson. We are
not required to agree to your request unless you are asking us to restrict the use and disclosure of
your Protected Health Information to a health plan for payment or health care
operation purposes and such information you wish to restrict pertains solely to
a health care item or service for which you have paid us “out-of-pocket” in
full. If we agree, we will comply with your request unless the information is
needed to provide you with emergency treatment.
Out-of-Pocket-Payments. If you paid
out-of-pocket (or in other words, you have requested that we not bill your
health plan) in full for a specific item or service, you have the right to ask
that your Protected Health Information with respect to that item or service not
be disclosed to a health plan for purposes of payment or health care
operations, and we will honor that request.
Right to Request Confidential Communications. You have the
right to request that we communicate with you about medical matters in a
certain way or at a certain location.
For example, you can ask that we only contact you by mail or at
work. To request confidential
communications, you must make your request, in writing, to Soddy Daisy Smiles. Your request must specify how or where you wish
to be contacted. We will accommodate
Right to a Paper Copy of This Notice. You have the
right to a paper copy of this notice.
You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this
notice electronically, you are still entitled to a paper copy of this
notice. You may obtain a copy of this notice
at our web site, www.soddydaisysmiles.com
To obtain a paper copy of this notice, contact Wanda Thompson at Soddy
CHANGES TO THIS NOTICE:
We reserve the right to change this notice and make
the new notice apply to Health Information we already have as well as any
information we receive in the future. We
will post a copy of our current notice at our office. The notice will contain the effective date on
the first page, in the top right-hand corner.
If you believe your privacy rights have been
violated, you may file a complaint with our office or with the Secretary of the
Department of Health and Human Services.
To file a complaint with our office, contact Soddy Daisy Smiles ATTN
Wanda Thompson. All complaints must be
made in writing. You will not be
penalized for filing a complaint.