NOTICE OF PRIVACY PRACTICES FOR DENTAL ASSOCIATES
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
USE AND DISCLOSURE OF HEALTH INFORMATION
Associates ("Provider") may use your health
information, that is, information that constitutes protected health
information as defined in the Privacy Rule of the Administrative
Simplification provisions of the Health Insurance Portability and
Accountability Act of 1996, for purposes of providing you treatment,
obtaining payment for your care and conducting health care operations. Provider has established a policy to guard
against unnecessary disclosure of your health information.
THE FOLLOWING IS A SUMMARY OF THE
CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY
BE USED AND DISCLOSED:
Provide Treatment. Provider may use your
health information to provide care to you and disclose your health information
to others who provide care to you.
For example, dentists involved in your care will need information
about your symptoms in order to prescribe appropriate medications. The Provider also may disclose your health
care information to individuals outside of the Provider involved in your care
including family members, pharmacists, suppliers of medical and dental
equipment or other health care professionals.
Payment. Provider may include your health
information in invoices to collect payment from third parties for the care
you may receive from Provider. For
example, Provider may be required by your health insurer to release
information regarding your health care status so that the insurer will
reimburse you or Provider. The Provider may be required to obtain prior
approval from your insurer and may need to explain to the insurer your need
for dental care and the services that will be provided to you.
Conduct Health Care Operations. Provider
may use and disclose health information for its own operations in order to
facilitate the function of Provider and as necessary to provide quality care
to all of Provider's patients. Health
care operations include activities such as:
- Quality assessment and improvement
- Activities designed to improve health
or reduce health care costs.
- Protocol development, case management
and care coordination.
- Contacting health care providers and
patients with information about treatment alternatives and other related
functions that do not include treatment.
- Professional review and performance
- Training programs including those in
which students, trainees or practitioners in health care learn under
- Training of non-health care
- Accreditation, certification, licensing
or credentialing activities.
- Review and auditing, including
compliance reviews, medical and dental reviews, legal services and compliance
- Business planning and development
including cost management and planning related analyses and formulary
- Business management and general
administrative activities of Provider.
Certain marketing activities of Provider.
Provider may use your health information to evaluate its staff performance,
combine your health information with other Provider patients in evaluating
how to more effectively serve all of Provider's patients or disclose your
health information to Provider staff and contracted personnel for training
For Appointment Reminders. Provider may use and disclose your health
information to contact you as a reminder that you have an appointment for
treatment or dental care with Provider.
Treatment Alternatives. Provider
may use and disclose your health information to tell you about or recommend
possible treatment options or alternatives that may be of interest to
When Legally Required.
Provider will disclose your health information when it is required to
do so by any Federal, State or local law.
When There Are Risks to Public Health. Provider may disclose your health
information for the following public activities and purposes:
- To prevent or control disease, injury or disability, report
disease, injury, vital events such as birth or death and the conduct of
public health surveillance, investigations and interventions.
- To report adverse events, product defects, to track products
or enable product recalls, repairs and replacements and to conduct
post-marketing surveillance and compliance with requirements of the Food and
- To notify a person who has been exposed to a communicable
disease or who may be at risk of contracting or spreading a disease.
To an employer about an individual who is a member of the workforce
as legally required.
Abuse, Neglect Or Domestic Violence.
Provider is allowed to notify government authorities if Provider
believes a patient is the victim of abuse, neglect or domestic violence. Provider will make this disclosure only
when specifically required or authorized by law or when the patient agrees to
Conduct Health Oversight Activities.
Provider may disclose your health information to a health oversight
agency for activities including audits; civil, administrative or criminal
investigations; inspections; licensure or disciplinary action. Provider, however, may not disclose your
health information if you are the subject of an investigation and the
investigation does not arise out of and is not directly related to your
receipt of health care or public benefits.
Connection With Judicial And Administrative Proceedings. As permitted or required by State law,
Provider may disclose your health information in the course of any judicial
or administrative proceeding in response to an order of a court or
administrative tribunal as expressly authorized by such order or in response
to a subpoena, discovery request or other lawful process. Reasonable efforts will be made to either
notify you about the request or to obtain an order protecting your health information.
Enforcement Purposes. As permitted or required by
State law, Provider may disclose your health information to a law enforcement
official for certain law enforcement purposes, including, under certain
limited circumstances, if you are a victim of a crime or in order to report a
Coroners And Medical Examiners. Provider
may disclose your health information to coroners and medical examiners for
purposes of determining your cause of death or for other duties, as
authorized by law.
Funeral Directors. Provider may disclose your
health information to funeral directors consistent with applicable law and if
necessary, to carry out their duties with respect to your funeral
arrangements. If necessary to carry
out their duties, Provider may disclose your health information prior to, and
in reasonable anticipation of, your death.
Organ, Eye Or Tissue Donation. Provider
may use or disclose your health information to organ procurement
organizations or other entities engaged in the procurement, banking or
transplantation of organs, eyes or tissue for the purpose of facilitating the
donation and transplantation.
Research Purposes. Provider may, under very
select circumstances, use your health information for research. Before Provider discloses any of your
health information for such research purposes, the project will be subject to
an extensive approval process.
Worker's Compensation. Provider may release your
health information for worker's compensation or similar programs.
Event of A Serious Threat To Health Or Safety. Provider may, consistent with applicable
law and ethical standards of conduct, disclose your health information if
Provider, in good faith, believes that such disclosure is necessary to
prevent or lessen a serious and imminent threat to your health or safety or
to the health and safety of the public.
Specified Government Functions. In
certain circumstances, the Federal regulations authorize Provider to use or
disclose your health information to facilitate specified government functions
relating to the military and veterans, national security and intelligence
activities, protective services for the President and others, medical
suitability determinations and inmates and law enforcement custody.
TO USE OR DISCLOSE HEALTH INFORMATION
Other than is stated above,
Provider will not disclose your health information other than with your
written authorization. If you or your
representative authorizes Provider to use or disclose your health
information, you may revoke that authorization in writing at any time.
RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION
You have the following rights
regarding your health information that Provider maintains:
Right to Request Restrictions. You may request restrictions on certain
uses and disclosures of your health information. You have the right to request a limit on Provider's disclosure
of your health information to someone who is involved in your care or the
payment of your care. However,
Provider is not required to agree to your request. If you wish to make a request for restrictions, please contact
the compliance officer at (414) 778-5299.
Receive Confidential Communications.
You have the right to request that Provider communicate with you in a
certain way. For example, you may ask
that Provider only conduct communications pertaining to your health
information with you privately with no other family members present. If you wish to receive confidential
communications, please contact the compliance officer at (414) 778-5299. Provider will not request that you provide
any reasons for your request and will attempt to honor your reasonable
requests for confidential communications.
Right to Inspect and Copy Your Health Information. You have the right to inspect and copy
your health information, including billing records. A request to inspect and
copy records containing your health information may be made to the compliance
officer at 11711 W. Burleigh Street, Wauwatosa, WI 53222 or (414)
778-5299. If you request a copy of
your health information, Provider may charge a reasonable fee for copying and
assembling costs associated with your request.
Right to Amend Your Health Information. You or your representative have the right
to request that Provider amend your records, if you believe your health
information records are incorrect or incomplete. That request may be made as long as Provider maintains the
information. A request for an
amendment of records must be made in writing to the compliance officer, 11711
W. Burleigh Street, Wauwatosa, WI 53222.
Provider may deny the request if it is not in writing or does not
include a reason for the amendment.
The request also may be denied if your health information records were
not created by Provider, if the records you are requesting are not part of
Provider's records, if the health information you wish to amend is not part
of the health information you or your representative are permitted to inspect
and copy, or if, in the opinion of Provider, the records containing your
health information are accurate and complete.
an Accounting. You have the right to
request a list of certain disclosures of your health information that
Provider is required to keep a record of under the Privacy Rule and state
law. The request must be made in
writing to the compliance officer at 11711 W. Burleigh Street, Wauwatosa, WI
53222. The request should specify the
time period for which you are requesting the information, but may not start
earlier than April 14, 2003.
Accounting requests may not be made for time periods going back more
than six (6) years. Provider will
provide the first accounting you request during any 12-month period without
charge. Subsequent accounting
requests may be subject to a reasonable cost-based fee. Provider will inform you in advance of the
fee, if applicable.
Right to a Paper Copy of this Notice. You or your representative has a right to
a separate paper copy of this Notice at any time even if you or your
representative have received this Notice previously. To obtain a separate paper copy, please
contact the compliance officer at (414) 778-5299. A patient or a patient’s representative may also obtain a copy
of the current version of the Notice at, www.dentalassociates.com.
DUTIES OF PROVIDER
Provider is required by law to
maintain the privacy of your health information and to provide to you or your
representative this Notice of its duties and privacy practices. Provider is required to abide by the terms
of this Notice as may be amended from time to time. Provider reserves the right to change the terms of its Notice
and to make the new Notice provisions effective for all health information
that it maintains. If Provider makes
a material change to this Notice, Provider will provide a copy of the revised
Notice to you or your appointed representative. You or your representative
have the right to express complaints to Provider and to the Secretary of
Health and Human Services if you or your representative believe that your
privacy rights have been violated.
Any complaints to Provider should be made in writing to the compliance
officer at 11711 W. Burleigh Street, Wauwatosa, WI 53222. Provider encourages you to express any
concerns you may have regarding the privacy of your information. You will not be retaliated against in any
way for filing a complaint.
Provider has designated the
Compliance Officer as its contact person for all issues regarding patient
privacy and your rights under the Federal privacy standards. You may contact the Compliance Officer at
11711 W. Burleigh Street, Wauwatosa, WI 53222 or (414) 778-5299.
Notice is effective April 14, 2003.
YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT the Compliance Officer at
11711 W. Burleigh Street, Wauwatosa, WI 53222 or (414) 778-5299.