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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 applicable federal and state law to maintain the privacy
of your health information. We are also required to give you this Notice
about our privacy practices, our legal duties, and your rights concerning
your health information. We must follow the privacy practices that are
described in this Notice while it is in effect. This Notice takes effect
01/01/03 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 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 DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment,
and healthcare operations. For example:
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 services we provide to you.
Healthcare Operations: We may use and disclose
your health information in connection with our healthcare operations,
Healthcare operations include quality assessment and improvement activities,
reviewing the competence or qualifications of healthcare professionals,
evaluating practitioner and provider performance, conducting training
programs, accreditation, certification, 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 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 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 you
incapacity or emergency circumstances, we will disclose health information
based on a determination using our professional judgment disclosing
only
health information 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 health information.
Marketing Health-Related Services: We will
not use your health information for marketing communications without your
written authorization.
Required by Law: We may use or disclose
your health information when we are required to do so by law.
Abuse or Neglect: We may disclose your health
information to appropriate authorities if we reasonably believe that you
area possible victim of abuse, neglect, or domestic violence or the possible
victim of other crimes. We may disclose your health information to the
extent necessary to avert a serious threat to your health or safety or
the health or safety of others.
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. Appointment Reminders: We
may use or disclose your health information to provide you with appointment
reminders (such as voicemail messages, postcards, or letters).
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 usa letter
to the address at the end of this Notice. If you request copies, we will
charge you $0._____for each page,$_____per hour for staff time to locate
and copy
your
health information, and postage if you want the copies mailed to you, If
you request an alternative format, we will charge a cost-based 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.)
Disclosure
Accounting: You have the right to receive a list of instances
in which we or our business associates disclosed your health information
for purposes,
other
than treatment, payment, healthcare operations and certain other activities,
for the last 6 years, but not before April 14, 2003. If you request this
accounting
more than once in a12-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. We are not required to agree to these additional
restrictions, but if we do, we will abide by our agreement (except in
an emergency).
Alternative
Communication: You have the right to request that we communicate
with you about
your health information by alternative means or to alternative 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 you request.
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, 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
or disclosure of your health information or to have us communicate with you
by
alternative
means oral alternative locations, you may complain to us using the
contact information listed at the end of this Notice. 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 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.
Contact officer: Patricia
Larson
Telephone: 636-537-0447 Fax: 636-5375492 Email: pslarson@wildhorsedental.com
Address: 240 Long Road Ste.120
Chesterfield,
MO 63005
© 2002 American Dental Association
All Rights Reserved
Reproduction
and use of this form by dentists and their staff is permitted.
Any other use, duplication or distribution of this form by any other
party requires the prior written
approval of the American Dental Association.
This Form is educational
only, does not constitute legal advice, and covers only-federal,
not state, law (August
14, 2002).
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