SUMMITVIEW PEDIATRIC DENTISTRY
STATEMENT OF PRIVACY PRACTICES
THIS STATEMENT DESCRIBES HOW HEALTH INFORMATION ABOUT YOUR CHILD MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
We are dedicated to protect the privacy of your child’s health information. We provide this statement to you about our privacy practices, our legal duties, and your rights concerning your child’s health information. We follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect December 1, 2008 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.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about your child for treatment, payment, and healthcare operations. For example, we may use or disclose your child’s health information to a physician or other healthcare provider providing treatment to your child, or we may use and disclose your child’s health information to obtain payment for services we provide to your child. We may also use and disclose your child’s health information in connection with our healthcare operations, which include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, and licensing or credentialing activities.
In addition to our use of your child’s 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 child’s health information for any reason except those described in this Notice.
We must disclose your child’s health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to an authorized 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.
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 child’s care, of your child’s location, your child’s general condition, or death. If you are present, then prior to use or disclosure of your child’s 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 child’s 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.
We will NOT use your child’s health information for marketing communications.
We may use or disclose your child’s health information when we are required to do so by law. We may disclose your health child’s information to appropriate authorities if we reasonably believe that your child is a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your child’s health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorize 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.
We may also use or disclose your child’s health information to provide you with appointment reminders (such as automated voicemail messages, text messages, letters or postcards).
Request restriction of uses and disclosures of your protected health information: You may request that we place additional restrictions on our use or disclosure of your protected health information. We are not required to agree to these additional restrictions. However, if we agree, we will abide by our agreement, except in situations in which the restricted information is needed for emergency treatment. To be effective, our agreement to further restrictions must be in writing and signed by our privacy officer. We may terminate an agreement to further restrictions if we inform you of our termination. The termination will be effective for information created or received after we have informed you of our termination.
Access your protected health information: You have a right to inspect and obtain a copy of your protected health information that we maintain in a designated record set, with limited exceptions. Your request to inspect or obtain copies of your protected health information must be in writing. You must send your request to our contact person listed at the end of this notice. We will act on your request no more than 30 days after we receive it. If we do not maintain the protected health information that you have requested but we know where it is maintained, we will tell where to send your request for access. We may discuss the scope, format, and other aspects of the request with you if the discussion is necessary for a timely response. If you request photocopies of protected health information, we will charge a reasonable cost-based fee that includes only the cost of copying, staff time to copy, postage, and preparing an explanation or summary of the requested information if you tell us in advance that you only want a summary. You may request copies of protected health information that we maintain in a format other than photocopies. We will respond in the format that you request if the protected health information is readily producible in that format. If you request a format other than photocopies, we may charge you a cost-based fee for providing the information in that format. You may get in touch with the contact person identified at the end of this notice for more information about access.
Amend your protected health information: You have the right to have us amend protected health information or a record about you in a designated record set for as long as the protected health information or record is maintained in the designated record set. You must make the request in writing, direct it to the contact person listed at the end of this notice, and explain why your information should be amended. We will act on your request for an amendment no more than 30 days after we receive it. We may extend the time to respond by no more than 30 days if we do so in the manner permitted by law. If we accept your request to amend the protected health information, we will make reasonable efforts to notify (a) people you identify to us as having received the protected health information and need the amendment and (b) other people, including business associates, that we know have the protected health information and may have relied on the information to your detriment. We may deny your request for amendment if we did not create the protected health information that you wish to have amended or for other reasons. We will provide you a written explanation of our reasons if your request is denied. You may respond with a statement of disagreement. We will append your statement of disagreement to your protected health information or record if you ask us to do so.
Request an accounting of disclosures of your protected health information: You have a right to receive information about instances in which our business associates or we have disclosed your protected health information, with limited exceptions. The exceptions include information we disclose for treatment, payment, or health care operations and information we disclose to you or with your written authorization. You must make your request in writing and direct it to the contact person identified at the end of this notice. We will provide an accounting of disclosures from the effective date of the federal privacy rule (which is, in most cases, April 14, 2003) but for a period of no more than six years prior to the date on which the accounting is requested. The information may include the date on which the disclosure was made, the name and address (if we know the address) of the person or entity to which we disclosed protected health information, a description of the information that was disclosed, the reason for the disclosure, or other information that, by law, we may substitute for this information. We will act on your request for an accounting within 60 days after we receive it, unless we extend the time for an additional 30 days in the manner permitted by law. We will provide the first accounting in any 12-month period free of charge. We may impose a reasonable cost-based fee for any subsequent request for an accounting by the same individual within the same 12-month period. We will inform you about the fee in advance and permit you to avoid or reduce the fee by withdrawing or modifying your request for this subsequent accounting.
Receive confidential communications about your protected health information: You may request that we communicate with you about your protected health information by alternative means or at alternative locations. You must advise us that communication by this means or at this location is necessary to avoid endangering you. You must make the request in writing and direct it to the contact person identified at the end of this notice. We will accommodate your request if it is reasonable, specifies the alternative means or location, and permits us to collect premiums and pay claims required by your dental services plan. Receive printed notices of our privacy practices: If you obtained this notice only from our website or by electronic mail, you have the right to a printed copy. Please get in touch with the contact person identified at the end of this notice to obtain a printed copy of this notice.
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 child’s privacy rights, or you disagree with a decision we made about access to your child’s health information or in response to a request you made to amend or restrict the use or disclosure of your child’s 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 below. 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 child’s right to privacy of their 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. Our office contact is: email@example.com.