HAPPY TEETH PEDIATRIC DENTISTRY
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW YOUR PROTECTED HEALTH INFORMATION MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
THE PRIVACY OF YOUR PROTECTED HEALTH INFORMATION IS IMPORTANT TO US.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your protected health information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your protected health information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect October 28, 2021, 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 YOUR PROTECTED HEALTH INFORMATION
We use and disclose your protected health information about you for treatment, payment, and healthcare operations. For example:
Treatment: We may use or disclose your protected health information to a physician or other healthcare providers providing treatment to you.
Payment: We may use and disclose your protected health information to obtain payment for services we provide to you.
Healthcare Operations: We may use and disclose your protected 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 providers performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
Your Authorization: In addition to our use of your protected 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 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 protected health information for any reason except those described in this notice.
To Your Family and Friends: We must disclose your protected health information to you, as described in the Patient Rights section of this notice. We may disclose your protected 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 with Your Care: We may use of disclose your protected 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 used 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 prescriptions, medical supplies, x-rays, or other similar forms of health information.
Marketing Health-Related Services: We will not use your protected health information for marketing communications without your written authorization.
Required by Law: We may use or disclose your protected health information when we are required to do so by law.
Abuse or Neglect: We may disclose your protected 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 protected health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
Appointment Reminders: We may use or disclose your protected health information to provide you with appointment reminders (such as voicemail and/or e-mail messages, postcards, or letters).
Dental Insurance: We may use or disclose your protected health information to dental insurance companies on your behalf as required by law. You reserve the right not to report this information; however, a HIPAA compliant do not report form must be completed and signed and kept in your records.
Billing Entities: We may use or disclose your protected health information to outsourced billing entities in accordance by state law.
Access: You have the right to look at or get copies of your protected health information, with limited exceptions.
You must make a request in writing to obtain access to your protected health information. You may obtain a form to request access by using the contact information listed at the end of this notice. The first copy will be provided at no charge. For additional copies, we reserve the right to charge a reasonable fee for expenses such as copies and staff time. This fee is governed by state law. You may request access by sending us a letter to the address at the end of this notice. If you request additional copies, we will charge you $0.83 for each page, $18.00 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. For copies to be mailed to anyone other than you, the same fees apply and a release must be signed by you. The release will expire 90 days from the date of your endorsement. State law requires 15 days for requests to be fulfilled.
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclose your protected health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 months, 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 protected 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 protected health information by alternative means or to alternative location. 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 amend your protected 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.
QUESTIONS AND COMPLAINTS
If you would like 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 have 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 protected health information or to have us communicate with you by alternative means or at alternative locations, you may issue your complaint to us using 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. Their address is U.S. Department of Health and Human Services, 200 Independence Ave. SW, Washington DC, 20201.
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: Amy Cartner, Office Manager
Telephone: (704)872-6534 Fax: (704)872-9407 Email: firstname.lastname@example.org
Address: 734 Hartness Rd. Statesville, NC 28677