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 informa-tion. This Notice took effect 04/14/03 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 law. We will make the new Notice avail-able upon request.
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, another dentist, or an oral surgeon who
may be providing treatment in conjunction with our services. This includes extractions, exposures, or
other surgical procedures.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
This includes insurance companies. We do not file our insurance claims electronically at this time.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare
operations. Healthcare operations include staff training and assessment, accreditation or certifi-
cation for the practitioner or staff, community dental training programs and licensing activities.
TO YOUR FAMILY AND FRIENDS: We must disclose your health information to you, as described in the Patients 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 your health information to notify or assist in the notification of (includ-ing identifying or locating) a family member, your personal representative, or another person responsible for your care, of your loca-tion, 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 information that is directly rele-vant to the person’s involvement in your healthcare. We will also use our professional judgment in allowing a person to pick up supplies, x-rays, or other similar forms of health information. We will also disclose your health information to any orthodontist who is in charge of resuming your treatment in the event of your relocation. This includes our sending him payment information and x-rays, as well as your health information.
MARKETING HEALTH-RELATED SERVICES: We will not use your health information for marketing communications with-out your written authorization.
REQUIRED BY LAW: We may use or disclose your health information when we are required to do so by law. This includes:
Abuse or Neglect: We would disclose information to the proper authorities to avert a serious
threat to our patient’s health or safety.
National Security: We may disclose to military authorities, federal officials, correctional insti-
tuitions and law enforcement officials under special 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 practically do so. You must make a request in writing to obtain access to your health information. The form to request this access can be obtained 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.
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 1, 2003.
Restriction: You have the right to request that we place additional restrictions on our use of 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 alter-native means or alternative locations. (You must make your request in writing, and it must explain why the information should be amended.) 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.
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 if you disagree with a decision that we made about access to your health information or in response to a request that you made to amend or restrict 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 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 for Wilson Orthodontics: Karen Caron
Telephone: 301-733-5230 Fax: 301-733-6169
Address: 1118 Klick Way Hagerstown, MD 21742
