Your Authorization: In addition to our use of your health information for the following purposes, you may give us written authorization to use your health information or to disclose permitted by your authorization while it was in effect. Unless you give us written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.
Uses and Disclosures of Health Information
We use and disclose health information about you without authorization for the following purposes:
Treatment: We will use your health information to provide you with dental treatment or services, such as cleaning and examining your teeth or performing dental procedures. We may disclose heatlh information about you to dental specialists, physicians, or other health care professionals involved in your care.
Payment: We may use and disclose your health information to obtain payment from health plans and insurers for the care that we provide to you.
Health Care Operations: We may use and disclose health information about you in connection with health care operations necessary to run our practice, including review of our treatment and services, training,evaluating the performance of our staff and health care professionals, quality assurance, financial or billing audits, legal matters, and business planning and development.
To You or Your Personal Representative: 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 your personal representative, 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 responsbile 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 absence or incapacity or in emergency circumstances, we will disclose heatlh information based on a determination using our professional judgment disclosing only health information that is directly relevant to the persons'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 a prescription, radiographs, or other similar forms of health information.
Appointment Reminders: We may use or disclose your health information when contacting you to remind you of a dental appointment. We may contact you by using a postcard, letter or voicemail.
Disaster Relief: We may use or disclose your health information to assist in disaster relief efforts.
Required by Law: We may use or disclose your health informtion when we are required to do so by law.
Public Heath and Public Benefit: We may disclose patient health information for public health activities and purposes, which include: preventing or controlling disease, injury or disability; reporting births or deaths; reporting child abuse or neglect; reporting adverse reactions to medications or contracting or spreading a disease or condition.
Victims of Abuse, Neglect or Domestic Violence: We may disclose health information to the appropriate government authority about a patient whom we believe is a victim of abuse, neglect, or domestic violence.
Decedents: We may dislcose health information about a decedent as authorized or required by law.
National Security: We may disclose to military authority the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officicals health information required for lawful intelligence, counter-intelligence, and other national security activities. We may disclose to a correctional institution or law enforcement official having lawful custody the protected health information of an inmate or patient under certain circumstances.
Marketing Health-Related Services: We will not use your health information for marketing communications with out your written authorization.
Patient Rights
You have the following rights with respect to certain health information that we have about you. To exercise any of these rights, you must submit a written request to our privacy official listed at the end of this Notice.
Access: You may request to review or request a copy of your health information. You must make a request in writing to obtain access to your health information. We may deny your request under certain circumstances. You will receive written notice of a denial and can appeal it. We will provide a copy of your health informaion in a format you request if it is producible. If not readily producible, we will provide it in hard copy format or other format that is mutually agreeable. If your health information is included in an Electronic Health Record, you have the right to obtain a copy of it in an elctronic format and to direct us to send it to the person or entity you designate in an electronic format. We may charge a reasonable fee to cover our cost to provide you with copies of your health information.
Amend: If you believe that your health information is incorrect or incomplete, you may request that we amend it. Your request must be in writing, and it must explain why the information shoud be amended. We may deny your request under certain circumstances. You will receive written notice of a denial and can file a statement of disagreement that will be included with your health information that you believe is incorrect or incomplete.
Restrict Use and Disclosure: You may request that we restrict uses of your health information to carry out treatment, payment or health care operations or to your family member or friend involved in your care or the payment of your care. We may not (and are not required to) agree to your requested restrictions, with one exception. If you pay out of pocket in full for a service you receive from us and you request taht we not submit the claim for this service to your health insurer or health plan for reimbursement, we must honor that request.
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. We will notify you in advance of this fee and you may choose to modify or withdraw your request at that time.
Alternate Communication: You may request to receive communications of health information by alternate means or at an alternate lcoation. We will accommodate a request if it is reasonable and you indicate that communication by reqular means could endanger you. When you submit a written request to the privacy official listed at the end of this Notice, you need to provide an alternate method of contact or alternative address and indicate how payment for services will be handled.
Receive a Papaer Copy of this Notice: You have the right to a paper copy of this notice. You may ask us to give you a paper copy of the Notice at any time (even if you have agreed to receive the Notice electronically). To obtain a paper copy, please speak with and Administrative Assistant.
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 alternate means or at alternate locations, you may complain to us using the contact information listed at the end of this Notice. You may also 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.
Privacy Official: Stephanie Telephone: 315-788-0805 Fax: 315-788-4108
E-Mail: smile@docschonfield.com Address: 126 Bellew Avenue, Watertown, New York 13601