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, 2019, 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 formation 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. Stop by our office during open hours or 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 maybe made by our office.
Treatment: We will use and disclose your protected health information to provide, coordinate or manage your healthcare 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 dentists or physicians who may be treating you. For example, your protected health information may be provided to a dentist/physician to whom you have been referred to ensure that the dentist/physician has the necessary information to diagnose or treat you.
In addition, we may disclose your protected health information to another dentist/physician or health care provider (e.g., your general dentist, another specialist, radiologic service, or laboratory etc.) who, at the request of your dentist/physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment.
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.
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, licensing, and conducting or arranging for other business activities. For example, we may 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, health insurance 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.
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, (for example, if you are medically incapacitated in some way) we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. For example, 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. This information might be provided to you by a general newsletter or in person, such as recommending hygiene products. We cannot sell patient information without the patient’s express authorization, and that authorization is also required for certain marketing communications. We do not share patient information with third parties for marketing purposes without your consent.
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.
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; 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. The dental practice is also required by law to notify any affected individuals if a breach of unsecured patient information occurs.
Process and Proceedings: We may disclose your protected health information in response to a court or administrative order, subpoena, discovery request or other lawful processes, 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.
Any other uses and disclosures not in this Notice of Privacy Practices will only be done with a patient’s written authorization. Patients can revoke an authorization at any time, as long as it is in writing, except if: 1. the practice has already relied on the disclosure to use a patient’s information, the revocation does not apply under those disclosures and, 2. If the authorization was for purposes of obtaining insurance coverage, since other laws give insurance companies certain 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 and sign a release form and send it to the contact person listed herein to obtain access to your protected health information. You may also request for access by sending us a letter to the address at the end of this notice. If you request copies, we will charge you fees as allowed by law for copying materials/supplies, labor to copy your protected health information, and postage if the copies are 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 an explanation of our fee structure.
Accounting of Disclosures: You have the right to receive an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our office. An accounting will not include internal uses of information for treatment, payment, or internal operations, disclosures made to you or made at your request, or disclosures made to family members or friends in the course of providing your care. After April 14, 2016, the accounting will be provided for the past six(6) years. If you request this list more than once in a12-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 an explanation of our fee structure.
Restriction Requests: You have the right to request in writing 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 on use or disclosure of your information, except if two conditions are met:
- If a patient asks the practice not to disclose information about a health care item or service to a health plan for payment or health care operations purpose, and
- The practice has been paid in full for that item or service by the patient or by another on behalf of the patient.
If we do agree to any other restrictions, 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, and you may get one during our open office hours. Alternativly you may 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, 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.
For questions contact:
Bay Dental Group LLC
Custodian of Records
PO Box 949
California, MD 20619
E-mail: [email protected]