HIPAA PRIVACY FORM 1
Notice Of Privacy Practices
Purpose: This form, Notice of Privacy Practices, presents
the information that federal law requires us to give our patients
regarding our privacy practices.
We must provide this Notice to each patient beginning no later
than the date of our first service delivery to the patient, including
service delivered electronically, after April 14, 2003.
We must make a good-faith attempt to obtain written acknowledgement
of receipt of the Notice from the patient. We must also
have the Notice available at the office for patients to request
to take with them. We must post the Notice in our office
in a clear and prominent location where it is reasonable to expect
any patients seeking service from us to be able to read the Notice.
Whenever the Notice is revised, we must make the Notice available
upon request on or after the effective date of the revision in
a manner consistent with the above instructions. Thereafter,
we must distribute the Notice to each new patient at the time
of service delivery and to any person requesting a Notice.
We must also post the revised Notice in our office as discussed
above.
© 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).
Dr. William N. Myers D.D.S., P.C
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 (11/05/02), 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 your 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 are a 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 us a 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 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. 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 or at 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:
Tina Pressnall
Telephone:(574)
267-6651
Fax: (574) 267-6653
E-mail:
wmyers@kconline.com
Address:
2504 East Center Street, Warsaw, IN 46580
© 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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