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
duty, 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
03/04/03, 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
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 and disclose your health information
to a physician or other healthcare provider providing treatment
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 effect 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
To Your Family and Friends: We must disclose your
health information to you to notify, as described in the Patient
Rights sections 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 judgement disclosing
only health information that is directly relevant to the persons
involvement in your healthcare. We will also use our professional
judgement 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 safety or the health of 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 officials 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).
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.__ for each page, $___ 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 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 you complaint with the U.S. Department of
Health and Human Services.
Contact Officer: Alice Horrocks
Telephone: (202) 466-4530 Fax: (202) 842-0382
Address: 2112 F Street, N.W., Suite 605, Washington, DC 20037
© 2002 American Dental Association
All Rights Reserved
Reproduction and use of this form by dentists
and their staff is permitted. Any other use, duplication or
distribution of this form by any other party requires the
prior written approval of the American Dental Association.
In addition to our office Privacy Practices, we also have
our web site.