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Notice of Privacy Practices
Robert
C. Doshier D.D.S. P.A.
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
February 6, 2003, 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 may charge you $10.00 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:
Vickie Battenfield
Telephone: (870) 741-8551
Fax: (870) 741-7477
E-mail: vickie@doshierdds.com
Address: 125 Sisco Street, Harrison, AR 72601
© 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.
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