HIPAA
- 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
04/10/2003, 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 will charge you $0.10 for each paper page, $15
per hour for staff time to locate and copy your health information, $1.00
for each photographic print out page, $2.00 for each CD copy, 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.
Telephone: 408.354.7333 Fax: 408.354.7433
E-mail: info@losgatosdental.com
Address: 220 Oak Meadow Drive - Los Gatos, CA 95032
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