The
Kids' Dentist
NOTICE
OF PRIVACY PRACTICES
We are required by applicable federal and state law to maintain
the privacy of your health information. We are also required to give you this
Notice about our privacy practices, our legal duties, and your rights concerning
your health information. We must follow the privacy practices that are described
in this Notice while it is in effect. This Notice takes effect April 14, 2003
and will remain in effect until we replace it.
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.
We reserve the right to make the changes in our privacy practices and the
new terms of our Notice effective for all health information that we maintain,
including health information we created or received before we made the changes.
Before we make a significant change in our privacy practices, we will change
this Notice and make the new Notice available upon request.
You may request a copy of our Notice at any time. For more information about
our privacy practices, or for additional copies of this Notice, please contact
us using the information listed at the end of this Notice.
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USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health
information about you for treatment, payment, and healthcare operations. For
example:
Treatment: We may use or disclose your health
information to a physician or other healthcare provider providing treatment
to you.
Payment: We may use and disclose your health
information to obtain payment for services we provide to you.
Healthcare Operations: We may use and disclose
your health information in connection with our healthcare operations. Healthcare
operations include quality assessment and improvement activities, reviewing
the competence or qualifications of healthcare professionals, evaluating practitioner
and provider performance, conducting training programs, accreditation, certification,
licensing or credentialing activities.
Your Authorization: In addition to our use of
your health information for treatment, payment or healthcare operations, you
may give us written authorization to use your health information or to disclose
it to anyone for any purpose. If you give us an authorization, you may revoke
it in writing at any time. Your revocation will not affect any use or disclosures
permitted by your authorization while it was in effect. Unless you give us
a written authorization, we cannot use or disclose your health information
for any reason except those described in this Notice.
To Your Family and Friends: We must disclose
your health information to you, as described in the Patient Rights section
of this Notice. We may disclose your health information to a family member,
friend or other person to the extent necessary to help with your healthcare
or with payment for your healthcare, but only if you agree that we may do
so.
Persons Involved In Care: We may use or disclose
health information to notify, or assist in the notification of (including
identifying or locating) a family member, your personal representative or
another person responsible for your care, of your location, your general condition,
or death. If you are present, then prior to use or disclosure of your health
information, we will provide you with an opportunity to object to such uses
or disclosures. In the event of your incapacity or emergency circumstances,
we will disclose health information based on a determination using our professional
judgment disclosing only health information that is directly relevant to the
person’s involvement in your healthcare. We will also use our professional
judgment and our experience with common practice to make reasonable inferences
of your best interest in allowing a person to pick up filled prescriptions,
medical supplies,
x-rays, or other similar forms of health information.
Marketing Health-Related Services: We will not
use your health information for marketing communications without your written
authorization.
Required by Law: We may use or disclose your
health information when we are required to do so by law.
Abuse or Neglect: We may disclose your health
information to appropriate authorities if we reasonably believe that you are
a possible victim of abuse, neglect, or domestic violence or the possible
victim of other crimes. We may disclose your health information to the extent
necessary to avert a serious threat to your health or safety or the health
or safety of others.
National Security: We may disclose to military
authorities the health information of Armed Forces personnel under certain
circumstances. We may disclose to authorized federal officials health information
required for lawful intelligence, counterintelligence, and other national
security activities. We may disclose to correctional institution or law enforcement
official having lawful custody of protected health information of inmate or
patient under certain circumstances.
Appointment Reminders: We may use or disclose
your health information to provide you with appointment reminders (such as
voicemail messages, postcards, or letters).
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PATIENT RIGHTS
Access:
You have the right to look at or get copies of your health information, with
limited exceptions. You may request that we provide copies in a format other
than photocopies. We will use the format you request unless we cannot practicably
do so. (You must make a request in writing to obtain access to your health
information. You may obtain a form to request access by using the contact
information listed at the end of this Notice. We will charge you a reasonable
cost-based fee for expenses such as copies and staff time. You may also request
access by sending us a letter to the address at the end of this Notice. If
you request copies, we will charge you $0.25 for each page, $15 per hour for
staff time to locate and copy your health information, and postage if you
want the copies mailed to you. If you request an alternative format, we will
charge a cost-based fee for providing your health information in that format.
If you prefer, we will prepare a summary or an explanation of your health
information for a fee. Contact us using the information listed at the end
of this Notice for a full explanation of our fee structure.)
Disclosure Accounting: You have the right to
receive a list of instances in which we or our business associates disclosed
your health information for purposes, other than treatment, payment, healthcare
operations and certain other activities, for the last 6 years, but not before
April 14, 2003. If you request this accounting more than once in a 12-month
period, we may charge you a reasonable, cost-based fee for responding to these
additional requests.
Restriction: You have the right to request that
we place additional restrictions on our use or disclosure of your health information.
We are not required to agree to these additional restrictions, but if we do,
we will abide by our agreement (except in an emergency).
Alternative Communication: You have the right
to request that we communicate with you about your health information by alternative
means or to alternative locations. {You must make your request in writing.}
Your request must specify the alternative means or location, and provide satisfactory
explanation how payments will be handled under the alternative means or location
you request.
Amendment: You have the right to request that
we amend your health information. (Your request must be in writing, and it
must explain why the information should be amended.) We may deny your request
under certain circumstances.
Electronic Notice: If you receive this Notice
on our Web site or by electronic mail (e-mail), you are entitled to receive
this Notice in written form.
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QUESTIONS AND COMPLAINTS
If you want more information
about our privacy practices or have questions or concerns, please contact
us.
If you are concerned that we may have violated your privacy rights, or you
disagree with a decision we 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 us communicate with you by alternative
means or at alternative locations, you may complain to us using the contact
information listed at the end of this Notice. You also may submit a written
complaint to the U.S. Department of Health and Human Services. We will provide
you with the address to file your complaint with the U.S. Department of Health
and Human Services upon request.
We support your right to the privacy of your health information. We will not
retaliate in any way if you choose to file a complaint with us or with the
U.S. Department of Health and Human Services.
HIPAA Privacy Officer: Dana Anthony Yip, DDS, MS