Notice of Privacy Pracitces(HIPAA)

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.

Under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), all medical records and other individually identifiable protected health information (PHI) of which we have knowledge must be kept confidential. All PHI used by us or disclosed by us is covered by this Act regardless of whether this PHI is in electronic, oral or paper form. Several new rights are granted to patients under this Act, allowing control over how your PHI is used, how you can access it, and in some cases amend it.

We are required by law to maintain the privacy of your PHI and to provide you with notice of our legal duties and privacy practices with respect to your PHI.

We may be assessed a penalty for any misuse or unauthorized disclosures of your personal health information as regulated by HIPAA.

This Notice of Privacy Practices is effective on 9/23/2013

We are bound to abide by the terms of this notice and reserve the right to make revisions to this policy. Should revisions be made, you will be notified in writing, and a copy of the revised policy will be made available at your request.

Should any breach of unsecured PHI ever occur, we will notify the patient(s) involved within 10 business days of discovery of this breach.

You will be asked to sign a consent form authorizing us to use and disclose your personal health information only for the following purposes, as defined under the Act:

  • Treatment means the provision, coordination, or management of health care and related services by one or more healthcare providers, including the coordination of management of health care by a healthcare provider with a third party; consultation between healthcare providers relating to a patient; or the referral of a patient for health care from one healthcare provider to another. An example of this would be a dentist referral to an orthodontist.
  • Payment means obtaining reimbursement for the provision of health care; determinations of eligibility of coverage; billing; claims management; collection activities; justification of charges; and disclosure to consumer reporting agencies; protected health information relating to the collection of reimbursements (only certain information may be disclosed). An example of this would be submitting your bill for health care services to your insurance company.
  • Health care operations are any activity related to covered functions in which we participate in the function of our offices, such as conducting quality assessment activities; protocol development; case management and care coordination; auditing functions; business management and general administrative activities, including implementation of this regulation; customer service evaluations; resolution of grievances; fundraising; and marketing for which an authorization is not required. An example of this would be evaluation customer service given to patients.

We may, without prior consent use or disclose your PHI to carry out treatment, payment or health care operations:

  • Directly to you at your request;
  • In an emergency treatment situation, if we attempt to obtain such consent as soon as reasonably practicable after the delivery of such treatment, if we are required by law to treat you and attempts to obtain consent are unsuccessful, or if we attempt to obtain consent but are unable, due to barriers of communication, but we determine in our professional opinion that treatment is clearly inferred from the circumstances;
  • Pursuant to and in compliance with an authorization signed by you; and
  • Provided that you are informed in advance of the use and disclosure and have the opportunity to agree to or prohibit or restrict the use or disclosure. This may be an oral agreement between us and may include a directory maintained at our facility containing specific information allowed by the Act.

We may de-identify your personal health information by using codes or removing all individually identifiable health information.

All other uses and disclosures will be made only upon securing a written authorization form signed by you. You have the right to revoke this authorization, at any time, upon written notice and we will abide by that request.

However, exception would be any actions already taken, relying on your authorization, and prior to revocation notice.

If you have paid for services out of pocket, in full, and request that we not disclose PHI related solely to these services to a health plan, we will abide by this request except where required by law to make a disclosure.

We may contact you to provide appointment reminders or to inform you about treatment alternatives or other health related benefits or services that may be of interest to you.

A written authorization from you will be required to release the following information:

  • Use and disclosure of psychotherapy notes.
  • Use and disclosure of PHI for marketing purposes
  • Disclosures that constitute the sale of PHI
  • Other uses and disclosures of PHI not described in this Notice of Privacy Practices

Under HIPAA, you have the following rights with respect to your protected health information:

  • No use or disclosure of genetic information will be released for underwriting purposes.
  • You have the right to request restrictions on certain uses and disclosures of protected health information, including restrictions placed upon disclosure to family members, close personal friends, or any other person you may identify. We are, however, not required to agree with a requested restriction;
  • You have the right to receive confidential communications of your protected health information, either directly from us or from us by alternative means or from alternative locations;
  • You have the right to inspect and copy your protected health information; You may also request your PHI in an electronic format if we use an electronic (paperless) recordkeeping system.
  • You have the right to amend PHI, however, this request may be denied under certain circumstances;
  • You have the right to receive an accounting of disclosures of your protected health information made by us in the six years prior to the date of the account request; and
  • You have the right to obtain a paper copy of this notice from us, even if you have already agreed to receive the notice electronically

If you feel your privacy rights or the provisions of this notice of privacy policies has been violated, you have the right to file a formal written complaint.

 

Notice Of Privacy Practices

Purpose: This form, Notice of Privacy Practices, presents the information that federal law requires us to give our patients regarding our privacy practices. 

We must provide this Notice to each patient beginning no later than the date of our first service delivery to the patient, including service delivered electronically, after April 14, 2003.  We must make a good-faith attempt to obtain written acknowledgement of receipt of the Notice from the patient.  We must also have the Notice available at the office for patients to request to take with them.  We must post the Notice in our office in a clear and prominent location where it is reasonable to expect any patients seeking service from us to be able to read the Notice.  Whenever the Notice is revised, we must make the Notice available upon request on or after the effective date of the revision in a manner consistent with the above instructions.  Thereafter, we must distribute the Notice to each new patient at the time of service delivery and to any person requesting a Notice.  We must also post the revised Notice in our office as discussed above.

EMBASSY DENTAL

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.
  THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY
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 (01/01/05), 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 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).

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 $25.00 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. 

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.

Contact Officer:  Vicki Gorlitz, VP                                                                                       

Telephone:  615-620-5990                                   Fax:  615-620-5997                                  

E-mail:  vgorlitz@embassydental.com                                                                               

Address:  2505 21st Ave. S., Unit 204, Nashville, TN 37212