Effective Date: August 7, 2017
Revised: October, 2020
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.
Your Smile Doctors practice (the “Practice”) is required by law to maintain the privacy of protected health information, to provide individuals with notice of its legal duties and privacy practices with respect to protected health information (“PHI”), and to notify affected individuals following a breach of unsecured protected health information. The Practice must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect August 9, 2017, and will remain in effect until the Practice replaces it.
The Practice reserves the right to change its privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law, and to make new Notice provisions effective for all protected health information that the Practice maintains. When the Practice makes a significant change in its privacy practices, it will change this Notice and post the new Notice clearly and prominently at its practice location, and it will provide copies of the new Notice upon request.
You may request a copy of the Practice’s Notice at any time. For more information about the Practice’s privacy practices, or for additional copies of this Notice, please contact the Practice using the information listed at the end of this Notice.
HOW THE PRACTICE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
The Practice may use and disclose your health information for different purposes, including treatment, payment, and health care operations. For each of these categories, the Practice has provided a description and an example. Some information, such as HIV-related information, genetic information, alcohol and/or substance abuse records, and mental health records, if applicable, may be entitled to special confidentiality protections under applicable state or federal law. The Practice will abide by these special protections as they pertain to applicable cases involving these types of records.
Treatment. The Practice may use and disclose your health information for your treatment. For example, it may disclose your health information to a physician/dentist, to dental auxiliaries, or to other healthcare providers providing treatment to you.
Payment. The Practice may use and disclose your health information to obtain reimbursement for the treatment and services you receive from the Practice or another entity involved with your care. Payment activities include billing, collections, claims management, and determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party. For example, the Practice may send claims to your health plan containing certain health information.
Healthcare Operations. The Practice may use and disclose your health information in connection with its healthcare operations. For example, healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performances, conducting training programs, accreditation, certification, licensing, or credentialing activities.
Individuals Involved in Your Care or Payment for Your Care. The Practice may disclose your health information to a family member, other relative, close personal friend, or any other individual identified by you relative to that person’s involvement in your care or in the payment for your care. If you are present, then prior to use or disclosure of your health information, the Practice will provide you with an opportunity to object to such uses or disclosures. In the event of your absence or incapacity or in emergency circumstances, the Practice will disclose health information based on a determination using its professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. Additionally, the Practice may disclose information about you to your personal representative. If a person has the authority by law to make health care decisions for you, the Practice will treat that personal representative the same way it would treat you with respect to your health information.
Appointment Reminders. The Practice may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, text messages, emails, postcards, or letters).
Disaster Relief. The Practice may use or disclose your health information to assist in disaster relief efforts.
Required by Law. The Practice may use or disclose your health information when it is required to do so by law.
Public Health Activities. The Practice may disclose your health information for public health activities, including disclosures to:
- Prevent or control disease, injury or disability;
- Report child abuse or neglect;
- Report reactions to medications or problems with products or devices;
- Notify a person of a recall, repair, or replacement of products or devices;
- Notify a person who may have been exposed to a disease or condition; or
- Notify the appropriate government authority if the Practice believes a patient has been the victim of abuse, neglect, or domestic violence.
National Security. The Practice may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. The Practice may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. The Practice may disclose to correctional institution or law enforcement official having lawful custody the protected health information of an inmate or patient.
Secretary of HHS. The Practice will disclose your health information to the Secretary of the U.S. Department of Health and Human Services when required to investigate or determine compliance with HIPAA.
Worker’s Compensation. The Practice may disclose your PHI to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law.
Law Enforcement. The Practice may disclose your PHI for law enforcement purposes as permitted by HIPAA, as authorized by law. These oversight activities include audits, investigations, inspections, and credentialing, as required by law, or in response to a subpoena or court order.
Health Oversight Activities. The Practice may disclose your PHI to an oversight agency for activities necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Judicial and Administrative Proceedings. If you are involved in a lawsuit or a dispute, the Practice may disclose your PHI in response to a court or administrative order. The Practice may also disclose health information about you in response to a subpoena, discovery request, or other lawful process instituted by someone else involved in the dispute, but only if efforts have been made, either by the requesting party or the Practice, to tell you about the request or to obtain an order protecting the information requested.
Research. The Practice may disclose information to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.
Coroners, Medical Examiners, and Funeral Directors. The Practice may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. The Practice may also disclose PHI to funeral directors consistent with applicable law to enable them to carry out their duties.
To Avert a Serious Threat to Health or Safety. The Practice may use and disclose your PHI when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
Fundraising. The Practice may contact you to provide you with information about its sponsored activities, including fundraising programs, as permitted by applicable law. If you do not wish to receive such information from the Practice, you may opt out of receiving the communications.
Business Associate. Some of the Practice’s activities are provided on its behalf through contracts with business associates. When the Practice enters into contracts to obtain these services, the Practice may need to disclose your protected health information to a business associate so that the business associate may perform the job which it has requested. However, the Practice requires its business associates to appropriately safeguard your information.
Other Uses and Disclosures of PHI
Your authorization is required, with a few exceptions, for disclosure of psychotherapy notes, use or disclosure of PHI for marketing and for the sale of PHI. The Practice will also obtain your written authorization before using or disclosing your PHI for purposes other than those provided for in this Notice (or as otherwise permitted or required by law). You may revoke an authorization in writing at any time. Upon receipt of the written revocation, the Practice will stop using or disclosing your PHI, except to the extent that it has already taken action in reliance on the authorization.
Your Health Information Rights
Access. You have the right to view or obtain copies of your health information, with limited exceptions. You must make the request in writing. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending the Privacy Official a message to the email address at the end of this Notice. If you request information that the Practice maintains on paper, the Practice may provide photocopies. If you request information that the Practice maintains electronically, you have the right to an electronic copy. The Practice will use the form and format your request if readily producible. The Practice will charge you a reasonable cost-based fee for the cost of supplies and labor of copying, and for postage if you want copies mailed to you. Contact the Privacy Official using the information listed at the end of this Notice for an explanation of its fee structure.
If you are denied a request for access, you have the right to have the denial reviewed in accordance with the requirements of applicable law.
Disclosure Accounting. With the exception of certain disclosures, you have the right to receive an accounting of disclosures of your health information in accordance with applicable laws and regulations. To request an accounting of disclosures of your health information, you must submit your request in writing to the Privacy Official. If you request this accounting more than once in a 12-month period, the Practice may charge you a reasonable, cost-based fee for responding to the additional requests.
Right to Request a Restriction. You have the right to request additional restrictions on our use or disclosure of your PHI by submitting a written request to the Privacy Official. Your written request must include (1) what information you want to limit, (2) whether you want to limit the Practice’s use, disclosure, or both, and (3) to whom you want the limits to apply. The Practice is not required to agree to your request except in the case where the disclosure is to a health plan for purposes of carrying out payment or health care operations, and the information pertains solely to a health care item or service for which you, or a person on your behalf (other than the health plan), has paid the Practice in full.
Alternative Communication. You have the right to request that the Practice communicates with you about your health information by alternative means or at alternative locations. You must make your request in writing. Your request must specify the alternative means or location and provide satisfactory explanation of how payments will be handled under the alternative means or location you request. The Practice will accommodate all reasonable requests. However, if the Practice is unable to contact you using the ways or locations you have requested, the Practice may contact you using the information it has.
Amendment. You have the right to request that the Practice amend your health information. Your request must be in writing, and it must explain why the information should be amended. The Practice may deny your request under certain circumstances. If the Practice agrees to your request, it will amend your record(s) and notify you of such. If the Practice denies your request for an amendment, it will provide you with a written explanation of why the Practice denied it and will explain your rights.
Right to Notification of a Breach. You will receive notifications of breaches of your unsecured PHI as required by law.
Electronic Notice. You may receive a paper copy of this Notice upon request, even if you have agreed to receive this Notice electronically on the Practice’s website or by electronic mail (e-mail).
Questions and Complaints. If you want more information about the Practice’s privacy practices or have questions or concerns, please contact the Privacy Official.
If you are concerned that the Practice may have violated your privacy rights, or if you disagree with a decision the Practice 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 the Practice communicate with you by alternative means or at alternative locations, you may complain to the Privacy Official using the contact information listed at the end of this Notice. You may also submit a written complaint to the Secretary of the U.S. Department of Health and Human Services. The Privacy Official will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.
The Practice supports your right to the privacy of your health information. The Practice will not retaliate in any way if you choose to file a complaint with the Practice or with the U.S. Department of Health and Human Services.
Telephone: 1 (877) 221-9008
Email Address: firstname.lastname@example.org