PATIENT HIPAA AWARENESS
This notice describes how protected health information about you or your child may be
used and disclosed to carry out treatment, payment and healthcare operations and how you can get access to this information. Please review it carefully.
Uses and disclosures of health information
We use and disclose health information about you for treatment, payment and healthcare
operations. Your protected health information (i.e., individually identifiable information, such as medical and dental histories, names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used or disclosed by us in one or more of the following respects:
- Treatment- To other health care providers (i.e., your physician, general dentist, oral surgeon, periodontist, etc.) in connection with our rendering orthodontic treatment to you.
- Payment-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 for services we provide to you.
- Healthcare Operations-To certifying, licensing and accrediting bodies (i.e., the American Board of Orthodontists, state dental boards, etc.) in connection with obtaining certification, licensure or accreditation.
- Internally, to all staff members who have any role in your treatment.
- To other patients and third parties who may see or overhear incidental disclosures about your treatment, scheduling, etc.
- To your family and close friends involved in your treatment.
- We may contact you to provide appointment reminders (such as email, voicemail messages, postcards, or letters) or information about treatment alternatives or other health related benefits and services that may be of interest to you.
- The office is engaged in clinical research projects with the overall intent of continually improving the quality of orthodontic care rendered. Permission is granted to utilize orthodontic records for teaching and scientific publications.
- There are additional situations when we are required to use or disclose your protected health information without your consent or authorization (i.e. reporting to law enforcement officials, government agencies, Judicial and Administrative Proceedings, for public health activities, workers compensations, or to avoid a serious threat to health or safety.
Any other uses or disclosures of your protected health information will be made only after
obtaining your written authorization, which you have the right to revoke.
Patient rights - Under the new privacy rules, you have the right to:
- Request restrictions (in writing) on the use and disclosure of your protected health information.
- Request confidential communication of your protected health information.
- Inspect and obtain copies of your health information through asking us.
- Amend or modify your protected health information in certain circumstances
- Receive an accounting of certain disclosures made by us of your protected health information for purposes other than treatment, payment, healthcare operations and other activities, for the last 6 years, but not before April 14, 2003.
- You may, without the risk of retaliation, file a complaint as to any violation by us of your privacy rights with us (by submitting inquiries to our Privacy Contact Person at our office address) or the United States of Health and Human Services (which must be filed within 180 days of the violation).
Our legal duty - We have the following duties under the privacy rules:
- By law, to maintain the privacy of protected health information and to provide you with this notice setting forth our legal duties and privacy practices with respect to such information.
- To abide by the terms of our Privacy Notice that is currently in effect.
- To advise you of our right to change the terms of this Privacy Notice and to make the new notice provisions effective for all protected health information maintained by us and that if we do so, we will provide you with a copy of the revised Privacy Notice.
Please note that we are not obligated to:
• Honor any request by you to restrict the use or disclosure of protected health information;
• Amend your protected health information if, for example, it is accurate and complete.
• Provide an atmosphere that is totally free of the possibility that your protected health information may be incidentally overheard by other patients and third parties.
This privacy notice is effective as of the date of your signature on the acknowledgement of receipt
of this notice. If you have any questions about the information in this notice, please ask
Contact Person or contact Get It Straight Orthodontics, PC.
Signature of Patient:
Signature of Parent or Legal Guardian if the patient is a minor:
Print Name of Parent or Legal Guardian: