SUMMARY OF NOTICE OF PRIVACY PRACTICES (PROVIDER)
The Notice of Privacy Practices covers services provided to you by our office. We are required by law to maintain the privacy of protected health information and to provide you with the Notice of our legal duties and privacy practices with respect to protected health information. Protected health information. is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
The Notice describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations. Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law. The Notice also describes your rights to access and control your protected health information. Further, the Notice informs you of your rights to complain to us or the Secretary of Health and Human Services if you believe your privacy rights have been violated by us.
We are required to abide by the terms of the Notice. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice. You may contact our office by, calling our Office Manager and requesting that a revised copy be sent to you in the mail, or asking for one at the time of your next appointment.
Please read this Notice carefully.
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.
If you have any questions about this Notice please contact: our Privacy Contact who is the OFFICE MANAGER.
We are required by law to maintain the privacy of protected health information and to provide you with this Notice of our legal duties and privacy practices with respect to protected health information. Protected health information. is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
We are required to abide by the terms of this Notice currently in effect. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice by, calling our Privacy Contact and requesting that a revised copy be sent to you in the mail, or asking for one at the time of your next appointment.
1. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
Uses and Disclosures of Protected Health Information for Treatment, Payment, or Operations
Your protected health information may be used by your dentist for treatment, payment and health care operations as described in this Section 1 without authorization from you. Your protected health information may be used and disclosed by your dentist, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of the dentist.s practice.
Following are examples of the types of uses and disclosures of your protected health care information that the dentist.s office is permitted to make without your specific authorization. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that may be made by our office.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party, consultations with another dentist, or your referral to another dentist for your diagnosis and treatment.
Payment: Your protected health information will be used, as needed, to obtain or provide payment for your dental services, including disclosures to other entities. This may include certain activities that your health insurance plan may undertake before it approves or pays for the services we recommend for you such as making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you, and undertaking utilization review activities.
Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your dentist’s practice. These activities include, but are not limited to: quality assessment and improvement activities; reviewing the competence or qualifications of professionals; securing stop-loss or excess of loss insurance; obtaining legal services or conducting compliance programs or auditing functions; business planning and development; business management and general administrative activities, such as compliance with the Health Insurance Portability and Accountability Act; resolution of internal grievances; due diligence in connection with the sale or transfer of assets of your dentist.s practice; creating de-identified health information; and conducting or arranging for other business activities.
For example, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your treating provider. We may also call you by name in the waiting room when your treating provider is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.
We will share your protected health information with third party business associates that perform various activities (e.g., billing, transcription services, accounting services, legal services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.
We may use or disclose your protected health information, as necessary, to provide you with information about a product or service to encourage you to purchase or use the product or services for the following limited purposes: (1) to describe our participation in a dentist network or health plan network, or to describe if, and the extent to which, a product or service (or payment for such product or service) is provided by our practice or included in a plan of benefits; (2) for your treatment; or (3) for your case management or care coordination, or to direct or recommend alternative treatments, therapies, dentists, or settings of care.
In addition, we may disclose your protected health information to another provider, health plan, or health care clearinghouse for limited operational purposes of the recipient, as long as the other entity has, or has had, a relationship with you. Such disclosures shall be limited to the following purposes: quality assessment and improvement activities, population-based activities relating to improving health or reducing health care costs, case management, conducting training programs, accreditation, certification, licensing, credentialing activities, and health care fraud and abuse detection and compliance programs.
Uses and Disclosures of Protected Health Information Based upon Your Written Authorization
Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke this authorization, at any time, in writing, except to the extent that your dentist or the providers practice has taken an action in reliance on the use or disclosure indicated in the authorization.
2. YOUR RIGHTS
Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in your chart, including medical and billing records and any other records that your dentist and the practice uses for making decisions about you.
Under federal law, however, you may not inspect or copy the following records: information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Contact if you have questions about access to your medical record.
You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice. Your request must state the specific restriction requested and to whom you want the restriction to apply.
Your dentist is not required to agree to a restriction that you may request. If your dentist believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If your dentist does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with the office privacy contact. You may request a restriction by speaking with the office manager who is the privacy contact.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Contact.
You may have the right to have your provider amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Contact to determine if you have questions about amending your medical record.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice. It excludes disclosures we may have made to you, for a facility directory, to family members or friends involved in your care, or for notification purposes, or disclosures for which you have signed an authorization. You have the right to receive specific information regarding these disclosures that occurred after February 25, 2019. You may request a shorter time-frame. The right to receive this information is subject to certain exceptions, restrictions and limitations.
You have the right to obtain a paper copy of this Notice from us, upon request, even if you have agreed to accept this Notice electronically.
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Contact of your complaint. We will not retaliate against you for filing a complaint.
Aqua Dental, 10507 E 91st St, Suite 410, Tulsa, OK 74133
Phone: 918-455-7700 | Fax: 918-455-5541
You may contact our Privacy Contact, the OFFICE MANAGER for further information about the complaint process.
This Notice was published and becomes effective on February 25, 2019.
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Tulsa, OK 74133