Notice of Privacy Practices

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.

We understand that the medical/Dental information that is provided and recorded about you and your health is personal. The confidentiality and privacy of your Dental/health information is also protected under state and federal law.

This Notice of Privacy Practices describes how this office may use and disclose your information and the rights that you have regarding your health information.

Treatment: We will use your Dental/health information for treatment. For example: information obtained by the orthodontist or other members of your Dental/healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your orthodontist will document in your record his or her expectations of the members of your healthcare team. Members of your Dental/healthcare team will then record the actions they took and their observations, so the orthodontist will know how you are responding to treatment. We may also provide your physician, or a subsequent healthcare provider, with copies of various reports that should assist him or her in treating you.

Payment: We will use your Dental/health information for payment. For example: a bill may be sent you or your Dental/health plan. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.

Health Care Operations: We will use your Dental/health information for our regular health care operations. For example: we may use information your Dental/health record to access the care and outcome in your case and others like it. This is information will then be used in a continued effort to improve the quality and effectiveness of the service we provide.

Business Associates: We may enter into contracts with persons or entities known as business associates/subcontractors that provide services to or perform functions on our behalf. Examples include our accountants, consultants, and attorneys. We may disclose your Dental/health information to our business associates/subcontractors so they can perform the job we have asked them to do, once they have agreed in writing to safeguard your information.

Notifications: We may use or disclose information to assist in notifying a family member, personal representative, or another person responsible for your cares, of your location, and general condition. If we are unable to reach your family member or personal representative, then we may leave a message for them at the phone number that they have provided to us, e.g., on an answering machine.

Communication with Family: We may disclose to a family member, other relative, close personal friend, or any other person you identify, Dental/health information relevant to that person’s involvement in your care or payment related to your care. As a service to our clients we may provide important phone calls that use a prerecorded message, (unencrypted) text, and/or (unencrypted) email. By providing your personal cell phone and/or landline phone number, email address, or any social media channels you are consenting to receive such calls, (unencrypted) texts, and (unencrypted) emails at the number/address/channels you have provided to our office.

Appointment Reminders/Dental-Health Benefits: We may contact you to provide appointment reminders or information about treatment alternatives or other Dental/health benefits that may be of interest to you.

Funeral Directors and Coroners: We may disclose your health information to funeral directors, and to coroners or medical examiners, to carry out their duties consistent with applicable law.

Organ Procurement Organizations: Consistent with applicable law, we may disclose your Dental/health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

Research: We may disclose your Dental/health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information. We may also disclose your Dental/health information to people preparing to conduct a research project, so long as the health information is not removed from us. We may also use and disclose your Dental/health information to contact you about the possibility of enrolling in a research study.

Fundraising: We may contact you as part of our fundraising efforts; however, you may opt-out of receiving such communications.

Food and Drug Administration (FDA): We may disclose to the FDA Dental/health information relative to adverse events with respect to food, supplements, product, and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.

Worker’s Compensation: We may disclose Dental/health information to the extent authorized by and go to the extent necessary, to comply with laws relating to workers’ compensation or other similar programs established by law.

Public Health Activities: As required by law, we may disclose your Dental/health information to public health, or legal authorities, charged with preventing or controlling disease, injury, or disability.

Health Oversight Activities: We may disclose your Dental/health information to health oversight agencies for purposes of legally authorized health oversight activities, such as audits and investigations necessary for oversight of health care system and government benefit programs.

Correctional Institution: Should you be an inmate of a correctional institution, we may disclose to the institution, or agents thereof, Dental/health information necessary for your health and the health and safety of other individuals.

Judicial & Administrative Proceedings: We may disclose you Dental/health information in a judicial or administrative proceeding if the request for the information is through an order from a court or administrative tribunal. Such information may also be disclosed in response to a subpoena or other lawful process if certain assurances regarding notice to the individuals or a protective order are provided.

Law Enforcement Purposes/Serious Threat to Health or Safety: We may disclose your Dental/health information to enforcement officials for law enforcement purposes under certain circumstances and subject to certain conditions. We may also disclose your Dental/health information to prevent or lessen a serious and imminent threat to a person or the public (when the disclosure is made to someone we believe can prevent or lessen the threat) or to identify or apprehend an escapee or violent criminal.

Victims of Abuse, Neglect, and Domestic Violence: In certain circumstances, we may disclose your Dental/health information to appropriate government authorities if there are allegations of abuse, neglect, or domestic violence.

Essential Government Functions: We may disclose your Dental/health information for certain essential government functions (e.g., military activity and for national security purposes

The following uses and disclosures will be made only with your authorization: (i) with limited exceptions, uses and disclosures of your Dental/health information for marketing purposes, including subsidized treatment communications, (ii) disclosures that constitute a sale of your Dental/health information; and (iii) other uses and disclosures not described in this notice. You may revoke your authorization at any time in writing, except to the extent that we will have taken action in reliance on the use or disclosure indicated in the authorization.

Although your Dental/health record is the physical property of this office, you have the following rights with respect to your health information:

• You may request that we not use or disclose your Dental/health information for a particular reason related to treatment, payment, our general healthcare operations, and/or to a particular family member, other relatives or close personal friend. We ask that such requests be made in writing on a form provided by us. Although we will consider your request, please be aware that we are under no obligation to accept it or to abide by it, except as provided below.

• If you have paid for services out-of-pocket in full, you may request that we not disclose information related solely to those services to your Dental/health plan. We ask that such requests be made in writing on a form provided by us. We are required to abide by such a request, except where we are required by law to make a disclosure. We are not required to inform other providers of such request, so you should notify any other providers regarding such a request.

• You have the right to receive confidential communications from us by alternative means or at an alternative location. Such a request must be made in writing, and submitted to the Administrator. We will attempt to accommodate all reasonable requests.

• You may request to inspect and/or obtain copies of Dental/health information about you, which will be provided to you in the time frames established by law. If we maintain your Dental/health information electronically in a designated record set, you may obtain an electronic copy of the information. If you request a copy (paper or electronic), we will charge you a reasonable, cost-based fee.

• If you believe that any Dental/health information in your record is incorrect, or if you believe that important information is missing, you may request that we correct the existing information or add the missing information. Such request must be made in writing, and must provide a reason to support the amendment. We ask that you use the form provided by us to make such requests. For a request form, please contact the Privacy Officer.

• You may request that we provide you written accounting of all disclosures made by us during the time period for which you request (not to exceed six years), as required by law. We ask that such requests be made in writing on a form provided by us. Please note that accounting does not include all disclosures, e.g., disclosures to carry our treatment, payment, or Dental/healthcare operations and disclosures made to you or your legal representative or pursuant to an authorization. You will not be charged for your first accounting request in any 12-month period. However, for any request that you make thereafter, you will be charged a reasonable, cost-based fee.

• You have the right to be notified following a breach of your unsecured protected health information.

• You have the right to obtain a paper copy of our Notice of Privacy Practices upon request.

You have the right to complain to us and to the Secretary of the U.S. Department of Health and Human Service (HHS) if you believe we have violated your privacy rights. We will not retaliate against you for filing a complaint.

For more information, contact our Privacy Officer by phone or mail as follows:

PHONE
Privacy Officer
423-894-6318

MAIL
Dr. Keith Dressler
6820 Lee Highway
Chattanooga, TN 37421

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, and to make new Notice provision effective for all protected health information that maintain. When we make a significant change in our Privacy Practice, we will change this Notice and post the new Notice clearly and prominently at our practice location, and we will provide copies of the new Notice upon request.

This notice is required by the new patient privacy regulations issued by the Untied States Department of Health and Human Services (HHS), and describes how your medical information may be used or disclosed, and how you may gain access to your medical information.

Your protected medical information (i.e. individually identifiable information, such as: names, dates, phone or fax numbers, email addresses, and demographic data) may be used or disclosed by us in one or more of the following respects:

• To other health care providers (i.e.: your general dentist, oral surgeon, etc in connection with our rendering orthodontic treatment to you;
• To third party payers or spouses (i.e.: insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc in order to obtain payment on your account;
• To certifying licensing and accrediting bodies (i.e.: the American Board of Orthodontics, state dental boards, etc in connection with obtaining certification, licensure, or accreditation;
• Internally, to all staff members who have any role in your treatment; and/or
• To other patients and third parties who may overhear conversations about your treatment, scheduling, etc.

Under the new privacy rules, you have the right to:

• Request restrictions on the use and disclosure of your protected health information;
• Request confidential communication of your protected health information;
• Inspect and obtain copies of your protected health information through asking us;
• Amend or modify your protected health information;
• Receive and accounting of certain disclosures made by us of your protected health information; and
• You may file a complaint with the HHS Secretary as to any violation by us of your privacy rights, which must be files within 180 days of the violation.

We have the following duties under the privacy rules:

• To only utilize your protected health information as set forth in the attached Consent and/or Authorization;
• To obtain, your written consent to use your protected patient information for treatment, payment, or health care operations, and to refuse treatment if you refuse to sign the consent;
• To obtain, your written authorization to use your protected patient information for any purpose other than treatment, payment, or health care operations;
• To use reasonable efforts to limit the amount of protected health information that is used, disclosed, or requested for purposes other than treatment; and,
• To obtain satisfactory assurances from our business associates who render services to our office that your protected health information will be safeguarded by them

To only utilize your protected health information as set forth in the attached Consent and/or Authorization;

Please note that we are not obligated to:

• Honor any request by you to restrict the use or disclosure of your protected health information;
• Amend your protected health information if for example, it is accurate and complete; or,
• Provide and atmosphere that is totally free of the possibility that your protected health information may be over heard by other patients and third parties.

 

If you have any questions about the information in this notice, please let us know.

*You May Refuse to Sign this Acknowledgement*

I, _______________, have received a copy of this office’s Notice of Privacy Practices.

Unencrypted Text Message – Email Language

We offer regular text message and email to provide helpful information like appointment reminders. Regular text messages and emails are not secured by a technical process called encryption so there may be some level of risk the information could be read by someone besides you. Please let us know if you would like us to communicate with you by text message or email.

 

I will let you know right away if my cell phone number changes.

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

• Individual refused to sign
• Communications barriers prohibited obtaining the acknowledgement
• An emergency situation prevented us from obtaining acknowledgement
• Other (Please Specify)

This form is required by the new patient privacy regulations recently issued by the United States Department of Health and Human Services (HHS Prior to commencing your orthodontic treatment, you must review, sign, and date this form.

Your protected health information (i.e.: individually identifiable information such as names, dates, phone or fax numbers, email addresses, and demographic data) may be used in connection with your treatment, payment of your account, or health care operations (i.e.: performance reviews, certification, accreditation, and licensure

You have the right to review our office’s privacy notice prior to signing this consent, a copy of which was given to you with this consent.

You have the right to request restrictions on the use of your protected health information. However, we are not required to, and may not, honor your request.

We may amend the attached privacy notice at any time. If we do, we will provide you with a copy of the changes, and the changes may not be implemented prior to the effective date of revised notice.

You may revoke this consent at any time in writing. However, such revocation will not be effective to the extent that any action has been taken in reliance on this consent.

Thank you for you cooperation. Please let us know if you have any questions.

If patient is a minor, must have both mother and father’s signature, if applicable.

This Authorization is required by the privacy regulations recently promulgated by the United States Department of Health and Human Services (HHS

Your protected health information, including individually identifiable information, such as names, dates, phone or fax numbers, email addresses, demographic data, photographs, x-rays, study models, and ________________  (identify specific data) will be used or disclosed for the purpose of (check all that apply):

• Lectures or presentations;
• Publications;
• Research;
• Practice Marketing; and/or,
• Other (specify): Facebook, YouTube, Twitter and/ or our Website

This information will be disclosed by the following people: ________________ 

The information will be disclosed by the following people/entities: ________________ 

This Authorization does not expire unless out office receives a written request.

You have the right to revoke this Authorization at any time in writing; however, your revocation will not be effective to the extent that this Authorization has been relied on.

The information used or disclosed per this Authorization may be subject to re disclosure by the recipient(s), and thus, no longer protected by the privacy rules.

I hereby authorize Dr. Keith B. Dressler and/or representatives (staff) to communicate confidential health information and financial information to the following individuals:

As a service to our clients we may provide important phone calls that use a prerecorded message, unencrypted text, and/or unencrypted email. By providing your personal cell phone and/or landline phone number, email address, or any social media channels you are consenting to receive such calls, texts, and emails at the number/address/channels you have provided to our office.