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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. {Note: this
form may need to be changed to reflect the dental practice's particular
privacy policies and/or stricter state laws.}
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).
ROCKVILLE DENTAL ARTS
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 (04/14/2003), 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 $0.25 for each page, $15 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: Dennis S. Norkiewicz, DDS Telephone: 301-424-2030
E-mail: info@rockvilledentalarts.com
Address: 1107 Nelson Street, Suite 201, Rockville, MD 20850
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