THIS NOTICE DESCRIBES HOW PROTECTED HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Aglow Dental Studio, is committed to preserving the privacy and confidentiality of your health information. This Notice of Privacy Practices describes how we may use and disclose your protected health information, referred to as “PHI,” to carry out treatment, payment or office procedures and for other purposes that are permitted or required by law. This notice is effective 8/1/2020. You may access or obtain a copy according to the following options: 1) our website at www.Aglowdentalstudio.com 2) contact the office and request a copy to be sent to you by mail or email, 3) request a copy at the time of your next appointment.
Get an electronic or paper copy of your medical / dental record: You can ask to see or get an electronic or paper copy of your PHI. Ask us how to do this. We will provide a copy or a summary of your health information within 30 days of your request. We may charge a reasonable fee.
Ask us to amend your medical record: You have the right to request we amend your health information that you believe to be incomplete or incorrect. We may deny your request, but we will provide you an explanation in writing within 60 days.
Request confidential communications: You can ask us to contact you in a specific way (for example, home, office or cell phone) or to send mail to a different address. We will accommodate all reasonable requests.
Ask us to limit what we use or share: You can ask us not to use or share certain health information for treatment, payment or office procedures. We are not required to agree to your request, and we may say “no” if it would affect your care.
If you pay for a service or healthcare item out of pocket, in full, you can ask us not to share that information for the purpose of payment or our operations with your insurance provider.
Get a list of those with whom we’ve shared information: You can ask for a list (accounting) of the times we’ve shared your PHI for six (6) years prior to the date you ask, who we shared it with and why. We will include all disclosures except for those about treatment, payment and office procedures, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but may charge a reasonable fee if you ask for another one within twelve (12) months.
Get a copy of this privacy notice: You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you: If you have given someone medical power of attorney, that person can exercise your rights and make choices about your health information. We will make sure that person has authority and can act for you before we take any action.
File a complaint: You can file a complaint if you feel we have violated your rights by contacting:
Aglow Dental Studio
11150 Sunset Hills Road, Suite 303, Reston, Virginia 20190
info@aglowdentalstudio.com
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20210, calling 877-696-6775, or visiting www.hhs.gov/ocr/privacy/hippa/complaints/.
We will not retaliate against you for filing a complaint.
In these cases, you have both the right and choice to:
- Share information with your family, friends, or others involved in your care.
- Share information in a disaster relief situation.
- Contact you for fundraising efforts.