The Village Dentist., P.C.
Notice of Privacy Practices
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 carefully.
Protected health information, about you is maintained as a record of your contacts or visits for healthcare services with our clinic. Specifically, “protected health information” is information about you, including demographic information (i.e. name, address, phone, etc.) that may identify you and relates to your past, present or future physical or mental health condition and related health care services.
We are required to follow specific rules on maintaining the confidentiality of your protected health information, using your information, and disclosing or sharing this information with other healthcare professionals involved in your care and treatment. This Notice describes your rights to access and control your protected health information. It also describes how we follow applicable rules and use and disclose your protected health information to provide your treatment, obtain payment for services you receive, manage our healthcare operations and for other purposes that are permitted or required by law. If you have any questions about this Notice, please contact our Privacy Manager.
Following is a statement of your rights, under the Privacy Rule, in reference to your protected health information. Please feel free to discuss any questions with our staff.
You have the right to receive, and we are required to provide you with a copy of this Notice of Privacy Practices – We are required to follow the terms of this notice. We reserve the right to change the terms of this notice, at any time. If needed, new versions of this notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with a revised Notice of Privacy Practices if you call our office and request that a revised copy be sent to you in the mail or ask for one at the time of your next appointment.
You have the right to authorize other use and disclosure – This means you have the right to authorize or deny any other use or disclosure of protected health information that is not specified within this notice. You may revoke an authorization, at any time, in writing, except to the extent that your healthcare provider or our office has taken an action in reliance on the use or disclosure indicated in the authorization.
You have the right to designate a personal representative – This means you may designate a person with the delegated authority to consent to, or authorize the use or disclosure of protected health information.
You have the right to inspect and copy your protected health information – This means you may inspect and obtain a copy of protected health information about you that is contained in your patient record.
You have the right to request a restriction of your protected health information – This means you may ask us, in writing, not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that nay part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. In certain cases, we may deny your request for a restriction.
You have the right to request an amendment to your protected health information – This means you may request an amendment of your protected health information for as long as we maintain this information. In certain cases, we may deny your request for an amendment.
You have the right to request disclosure accountability – This means that you may request a listing of disclosures that we have made, of your protected health information, to entities or persons outside of our office other than the purposes of treatment, payment, healthcare operations, or a purpose authorized by you.
Following are examples of uses and disclosures of your protected health care information that we are permitted to make.
Treatment – We may use and disclose your protected health information to provide, coordinate, or manage your health care and any related service. This includes the coordination or management of your health care with a third party that is involved in your care and treatment. For example, we would disclose your protected health information, as necessary, to a pharmacy that would fill your prescriptions. We will also disclose protected health information to other health care providers who may be involved in your care and treatment. We may also call you by name in the waiting room when the healthcare provider is ready to see you. We may use or disclose your protected health information, as necessary, to contact you or remind you of your appointment. We may contact you by phone or other means to provide results from exams or tests and to provide information that describes or recommends treatment alternatives regarding your care. Also, we may contact you to provide information about health related benefits and services rendered by our office.
Payment – Your protected health information will be used, as needed, to obtain payment for your health care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.
Healthcare Operations – We may use or disclose, as-needed your protected health information in order to support the business activities of our practice. This includes, but is not limited to business planning and development, quality assessment, and improvement, medical review, legal services, and auditing functions, It also includes education, provider credentialing, certification, underwriting, rating, or other insurance related activities. Additionally, it includes business administrative activities such as customer service, compliance with privacy requirements, internal grievance procedures, due diligence in connection with the sale or transfer of assets, and creating de-identified information.
We may also use and disclose your protected health information in the following instances as outlined below. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information.
To Others Involved In Your Healthcare – Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person, you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care, general condition or death. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.
As Required By Law – We may use or disclose your protected health information to the extent that the use or disclosure is required by law.
For Public Health – We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information.
For Communicable Diseases – We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
For Health Oversight – We may disclose protected health information to a health oversight agency for the activities authorized by law, such as audits, investigations, and inspections.
In Cases of Abuse or Neglect – We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made in a manner that is consistent with the requirements of applicable federal and state laws.
To The Food and Drug Administration – products; to enable product recalls; to make repairs or replacements or to conduct post-marketing surveillance, as required.
For Legal Proceedings – We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.
To Law Enforcement – We may also disclose protected health information, as long as applicable legal requirements are met, for law enforcement purposes.
To Coroners, Funeral Directors, and Organ Donation – We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties as authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out his/her duties. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.
In Cases of Criminal Activity – Consisted with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
For Military Activity and National Security – When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military service.
For Workers’ Compensation – Your protected health information may be disclosed, by us as authorized to comply with workers’ compensation laws and other similar legally-established programs.
When an Inmate – We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.
Required Uses and Disclosures – Under the law, we must make disclosures about you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of the Privacy Rule.
You may address complaints to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Manager of your complaint.
Effective Date 4/14/03