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Privacy Notice

Bright Smiles Dental, PC

 

NOTICE OF PRIVACY PRACTICES

 

THIS NOTICE DESCRIBES HOW 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 March 1, 2008, and will remain in effect until we replace it.

 

We reserve the right to change our privacy practices and applicable law permits the terms of this Notice at any time, provided such changes.  We reserve the right to make the changes in our policy 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.

 

USE 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 of qualifications of healthcare professionals, evaluating performances, conducting training programs.

 

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 for treatment, payment, or operations. YOU are responsible for notifying us of any changes to your wishes in regards to how you wish for us to communicate with you or who is able to obtain information about you.

 

TO YOUR FAMILY AND FRIENDS:  We may disclose your health information to you only as described I 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 have signed an authorization consenting to disclosure. YOU are responsible for notifying us of any changes to your wishes in regards to how you wish for us to communicate with you or who is able to obtain information about you.

 

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 may use your health information for direct (from Bright Smiles to you – the patient) marketing communications without your written authorization.

 

REQUIRED BY LAW:  We may use or disclose your health information to the Department of Health charged with preventing and controlling diseases and legal authorities as required by law.

 

ABUSE or NEGLECT:  We may disclose your health information to appropriate authorities if we have reasonable belief 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 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 an inmate or patient under certain circumstances.

 

PATIENT RIGHTS

 

ACCESS:  You have the right to look at or get copies of our health information, with limited exceptions.  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 the 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 $10.00 for each family member that you request records for.  (Records consist only of current x-rays, no other information will be copied.) This is to cover the cost for copies, staff time to locate and copy the records and postage.  This fee must be paid in full before we will begin the process to copy your records.  We require 7 days to complete your request.

 

DISCLOSURE ACCOUTING:  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, for the last six years, but not before April 13, 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.

 

RESTRICTIONS:  You have the right to request that we place additional restrictions on our use or disclosure of your health information.  You must do so by writing your requests on the Patient Agreement & Acknowledgement Form provided to you at the first date of service after April 14, 2003.  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 on the Patient Agreement & Acknowledgement form.  Your request must specify the alternative means or location. 

 

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.

 

 

CELL PHONE USE:  Cell phones are not allowed in the clinical area of our practice.

 

 

QUESTIONS and CONCERNS

 

If you have questions and would like additional information, please contact us.

 

If you believe your privacy rights have been violated, you can file a complaint with the privacy officer.  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 Officer:    Clyent Myrie 

 

Telephone:           Tel:   256-721-5961    

                             Fax:  256-721-7950

 

Address:               8371 Hwy 72, West, Suite 208

                             Madison, AL    35758

 

Web:                    MadisonBrightSmiles.com

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