HIPAA Notice of Privacy Practices

This notice describes how medical information about you may bee used and disclosed and how you can get access to this information. Pleas review it carefully.

This Notice of Privacy Practices describes how we may use and disclose your protected health information (phi) to carry out treatment, payment or health care option (tpo) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected health information" is information about you, including demographic information, that may identify you and relates to your past, present or future physical or mental condition and related to health care services.

Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your dentist, our office staff and other outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay our healthcare bills, to support the operation of the physicians practice, and any other use by law.

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 of management of your health care with a third party. for example, your protected health information may be provided to a physician/dentist to whom you have been referred to ensure that the physician/dentist has necessary information to diagnose or treat you.

Payment
Your protected health information will be used, as needed, to obtain payment for your health care services. For example, we may contact your health insurer to certify your eligibility of benefit and obtain payment from other third parties, your relevant protected health information may be disclosed to the health plan.

Healthcare Operations
We may use or disclose, as needed, your protected information in order to support the business activities of your dentist’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to students that see patients at our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your dentist is ready see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

Persons Involved In Care
We may use or disclose your protected health information in the following situations without your authorization. These situations include as required by law public health issues as required by law, Communicable Diseases; Health Oversight; Abuse or Neglect; Food and Drug Administration requirements; Legal Proceedings; Law Enforcement; Coroners, Funeral Directors, Organ Donation Research; Criminal Activity; Military Activity; National Security; Workers Compensation; Inmates; Required Uses and Disclosures. Under the law, we must make disclosures to you and when required by the Secretary f the Department of Health and Human Services to investigate or determine our compliance with requirements of Section 164.500.

Other permitted and required uses and disclosures will be made only with your consent. Authorization or opportunity to object, unless required b law. You may revoke this authorization, at any time, in writing, except to the extent that your dentist‘s practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights
Although your health records are the physical property of the health care provider who completed it, you have certain rights with regards to the information contained therein. Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information.
This right is not absolute. In certain situations, such as psychotherapy notes, information compiled in reasonable anticipation of, or use in , a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. If we grant access, we will tell yo what, if anything, you have to do to get access. We reserve the right to charge a responsible cost-based fee for making copies.

You have the right to request a restriction of your protected health information.
This means you may ask us not to use or disclose any pat of your protected health information for the purpose of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in the Notice of Privacy Practices. Your request must state the specific restrictions requested and to whom you want the restrictions to apply.

We are not required to agree to a restriction that you may request. If we believe it is in your best interest to permit use and disclosure of your protected health information will not be restricted. You then have the right to use another healthcare professional. You have the right to request to receive confidential communication from us by alternative means or at an alternate location. You ave the right to obtain a paper copy of this notice from us. Upon request, even if you have agreed to accept this notice alternately i.e. electronically. You may have the right to have your dentist amend your protected health information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement an will provide you with a copy of any such rebuttal. (Your request must be in writing, and it must explain why the information should be amended.)

You have the right to receive an accounting of certain disclosures we have made. If any of your protected health information.
We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as a provided in this notice.

Questions and Complaints
If you need more information about our privacy practices or have questions or concerns, please contact us. We support your right to the privacy of your protected health information. You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may cay file a complaint with us by notifying your privacy contact of your complaint. We will not retaliate against you for filing a complaint.

Contact Officer: Sharad Pandhi DDS
Address: 5828 N Oracle Rd. Ste 100
Tucson, AZ 85704
Phone: (520-293-2166
Fax: (520) 203-2267

 

This notice was published and becomes effective on/before April 14, 2003.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with resect to protected health information. If you have any objections to this form, please ask to speak with our hipaa compliance officer in person or by phone at our main phone number.

Signature below is only acknowledgement that you have received this Notice of our Privacy Practices.

Smile Perfection Log

 
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WE ATTEMPTED TO OBTAIN WRITTEN ACKNOWLEDGEMENT OF RECEIPT OF OUR NOTICE OF PRIVACY PRACTICE, BUT ACKNOWLEDGEMENT COULD NOT BE OBTAINED BECAUSE:

______ INDIVIDUAL REFUSED TO SIGN

______ COMMUNICATIONS BARRIERS PROHIBITED OBTAINING THE ACKNOWLEDGEMENT

______ AN EMERGENCY SITUATION PREVENTED US FROM OBTAINING THE ACKNOWLEDGMENT

______ OTHER (PLEASE SPECIFY)