Notice of Privacy Policies
We are required new federal and state laws to
inform you of how we protect the confidentiality of your dental
health information generated during the course of treatment. We
must follow the privacy policies that are described in this Notice
while it is in effect. This Notice takes effect April 14, 2003,
and will remain in effect until we replace it.
This Notice describes the privacy policies of
Pleasant Valley Dental Care. Please review it carefully. The privacy of
your health information is important to us. First and foremost,
we strive to maintain confidentiality as far as your dental treatment
information. There are times, however, where identifiable health
information must be disclosed to specific entities such as your
insurance carrier. Herein we describe how this confidential dental
and health information is used and disclosed and how you can gain
access to this confidential information.
We reserve the right to change our privacy policies
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 policies effective for all health information
that we collect and maintain, including prior dental information
as well as information gathered before policy changes are determined
to be necessary. As changes in our privacy policies are made,
we will notify our patients of these changes and make amended
Notice of privacy policy statements 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.
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
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 professional judgment.
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 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).
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 $0.75, for each page
$15.00, 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 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 U.S. Department of Health and
Human Services.
Contact Officer: Diane Grange
Telephone: 801 621-3383
Fax: 801 334-7432
E-mail:
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