NOTICE OF PRIVACY PRACTICES (HIPPA)
THIS NOTICE DESCRIBES HOW MEDICAL AND DENTAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THE INFORMATION. PLEASE PRINT AND REVIEW CAREFULLY.
Light Street Dental is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. If you have questions about any part of this notice or if you want more information about the privacy practices at Light Street Dental please contact:
Nicole Forel, D.D.S. , Privacy Officer
Effective Date of This Notice: April 14, 2003
I. HOW LIGHT STREET DENTAL MAY USE OR DISCLOSE YOUR HEALTH INFORMATION
Light Street Dental collects health information from you and stores it in a chart and on a computer. This is your dental record. The dental record is the property of Light Street Dental, but the information in the dental record belongs to you. Light Street Dental protects the privacy of your health information. The law permits Light Street Dental to use or disclose your health information for the following purposes:
Treatment: Doctors and staff will need to discuss your health information to treat you safely. Staff helping with your care will need to know about certain health information so they can assist in providing treatment. We may also 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.
Regular Health Care Operations: Portions of your health information are disclosed for regular health care operations. This might include referrals to specialists which would require that your name and an explanation of the problem be disclosed to an affiliated office. Healthcare operations also 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.
Providing Information To You: You may receive a copy of your health information. A reasonable fee will be charged to cover duplication costs.
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.
Required By Law: As required by law, we may use and disclose your health information.
Public Health: As required by law, we may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting child abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure.
Health Oversight Activities: We may disclose your health information to health agencies during the course of audits, investigations, inspections, licensure and other proceedings.
Judicial And Administrative Proceedings: We may disclose your health information in the course of any administrative or judicial proceeding.
Law Enforcement: We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena and other law enforcement purposes.
Deceased Person Information: We may disclose your health information to coroners, medical examiners and funeral directors.
Public Safety: We may disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.
Specialized Government Functions: We may disclose your health information for military, national security, prisoner and government benefits purposes.
Worker’s Compensation: We may disclose your health information as necessary to comply with worker’s compensation laws.
Marketing: We will not use your health information for marketing communications without your written authorization.
Health Plan: We may disclose your health information to the sponsor of your health plan.
Change Of Ownership: In the event that Light Street Dental is sold or merged with another organization, your health information/record will become the property of the new owner.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voice mail messages, postcards, or letters).
II. WHEN LIGHT STREET DENTAL MAY NOT USE OR DISCLOSE YOUR HEALTH INFORMATION
Information: Except as described in this Notice of Privacy Practices, Light Street Dental will not use or disclose your health information without your written authorization. If you do authorize Light Street Dental to use or disclose your health information for another purpose, you may revoke your authorization in writing at any time.
Authorization: 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.
III. YOUR HEALTH INFORMATION RIGHTS
1. You have the right to request restrictions on certain uses and disclosures of your health information. Light Street Dental is not required to agree to the restriction that you requested. If we deny the request, we will provide you information about the denial and what steps you can take if you disagree.
2. You have the right to receive your health information through a reasonable alternative means or at an alternative location. A request must be made in writing to Light Street Dental, which will review the request in a timely manner and inform you of our decision. If we deny the request, we will provide you information about the denial and what steps you can take if you disagree.
3. You have the right to inspect and to request a copy your health information.
4. You have a right to request that Light Street Dental amend your health information that is incorrect or incomplete. Light Street Dental will consider each request to change your health information. If we deny the request, we will provide you information about the denial and what steps you can take if you disagree.
5. You have a right to receive an accounting of disclosures of your health information made by Light Street Dental, except that Light Street Dental does not have to account for the disclosures described in parts 1 (Treatment), 2 (Payment), 3 (Regular Health Care Operations), 4 (Providing Information to You), and 14 (Specialized Government Functions) of section I of this Notice of Privacy Practices.
6. You have a right to a paper copy of this Notice of Privacy Practices.
If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact the Privacy Officer, Nicole Forel, D.D.S. at 410-659-0900.
IV. CHANGES TO THIS NOTICE OF PRIVACY PRACTICES
Light Street Dental reserves the right to amend this Notice of Privacy Practices at any time in the future, and to make the new provisions effective for all information that it maintains, including information that was created or received prior to the date of such amendment. Until such amendment is made, Light Street Dental is required by law to comply with this Notice.
Revised Notices will be communicated to you at later appointments.
Complaints about this Notice of Privacy Practices or how Light Street Dental handles your health information should be directed to Light Street Dental. Upon completion of the form that Light Street Dental will provide to you, an investigation of your complaint will take place and written notification of the findings will be provided to you.
If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to:
Department of Health and Human Services
Office of Civil Rights
Hubert H. Humphrey Building
200 Independence Ave., S.W.
Room 509F HHH Bldg.
Washington, DC 20201
You may also address your complaint to one of the regional offices for civil rights. A list of these offices can be found online at http://www.hhs.gov/ocr/regmail.html.