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.
Under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), White Orthodontics is required by law to maintain the privacy of health information that identifies you, called protected health information, and to provide you with notice of our legal duties and privacy practices regarding your protected health information. White Orthodontics is committed to the protection of your protected health information and will make reasonable efforts to ensure the confidentiality of your protected health information, as required by statute and regulation. We take this commitment seriously and will work with you to comply with your right to receive certain information under HIPAA.
Your protected health information (i.e., individually identifiable information, such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used or disclosed by us in one or more of the following respects:
- To other health care providers (i.e., your general dentist, oral surgeon, etc.) in connection with our rendering orthodontic treatment to you (i.e., to determine the results of cleanings, surgery, etc.);
- To third party payers (i.e., insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of your account (i.e., to determine benefits, dates of payment, etc.);
- To certifying, licensing and accrediting bodies (i.e., the American Board of Orthodontics, state dental boards, etc.) in connection with obtaining certification, licensure or accreditation;
- Internally, to all staff members who have any role in your treatment;
- To other patients and third parties who may see or overhear incidental disclosures about your treatment, scheduling, etc.
- To your spouse, family, and/or close friends involved in your treatment and/or the payment of that treatment;
- To business associates of White Orthodontics who perform certain business functions or provide certain business services to White Orthodontics. For example, we may use another company to perform billing services on our behalf. All of our business associates are required to maintain the privacy and confidentiality of your protected health information. In addition, White Orthodontics may disclose protected health information to business associates of other health care providers and/or health plans for purposes of performing certain business functions or health care services on their behalf. For example, we may disclose protected health information to a business associate of a health plan for purposes of conducting quality assessment and improvement activities; and/or,
- We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Any other uses or disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke.
Uses and Disclosures that Require Your Consent:
- If you have paid for services out-of-pocket, in full, you have the right to request in writing that White Orthodontics not disclose protected health information related solely to those services to a health plan. White Orthodontics must accommodate your request, except when White Orthodontics is required by law to make a disclosure.
- Uses and disclosures of psychotherapy notes (if recorded by White Orthodontics).
- Uses and disclosures for marketing purposes, including subsidized treatment communications, unless it is a face-to-face communication or a promotional gift of a nominal value provided by White Orthodontics.
- Uses and disclosures that constitute a sale of protected health information.
- If White Orthodontics sends fundraising communications to you, you have the right to opt out of such fundraising communications with each solicitation.
- Other uses and disclosures not described in this Notice of Privacy Practices.
To send your written authorization to White Orthodontics, refer to the Privacy Contact Person at the end of this Notice of Privacy Practices.
You may revoke such authorization(s) at any time in writing, unless (1) White Orthodontics has already taken action in reliance upon the authorization you have provided; or (2) if the authorization was obtained as a condition of obtaining insurance coverage, and other law(s) provide the insurer the right to contest a claim under the policy.
Uses and Disclosures that Do Not Require Your Consent:
- Public health authorities in order to prevent or control disease, to report birth or death, and for the purpose of public health investigations, interventions, and other related matters.
- Government authorities, as required by law, of a person who may be a victim of abuse, neglect, or domestic violence.
- Agencies that oversee insurance health benefit programs for the purpose of audits, investigations, inspections, or other activities.
- A court order or subpoena in a judicial or administrative proceeding.
- Law enforcement officials for a law enforcement purpose in the following situations: when required by law; for identification and location purposes; if you are suspected to be a victim of a crime; to report suspicion of death by criminal conduct; to report suspicion of criminal conduct occurring on the grounds of our facility; and in the case of an emergency.
- A coroner, medical examiner, or funeral director in the event of your death.
- Organ donation organizations, if the insured has previously made those arrangements.
- Limited health information may be disclosed if necessary to prevent an immediate threat to the health or safety of the public.
- Special government circumstances involving: military or veterans activities; national security and intelligence activities; protective services for the President; medical suitability determinations; law enforcement custodial situations; and government programs providing public benefits.
- The Food & Drug Administration (FDA) or the Center for Disease Control (CDC) for reporting adverse events with respect to immunizations and or health screening tests.
All other uses or disclosures of your protected health information will be made only with your written authorization. You may revoke your written authorization at any time.
Under HIPAA, you have the right to:
- Request restrictions on the use and disclosure of your protected health information;
- Request confidential communication of your protected health information;
- Inspect and obtain copies of your protected health information by asking us;
- Amend or modify your protected health information in certain circumstances;
- Receive an accounting of certain disclosures made by us of your protected health information;
- Right to be notified of a breach in the event that White Orthodontics (or a business associate of White Orthodontics) discovers a breach of protected healthinformation, unless there is a demonstration, based on a risk assessment, that there is a low probability that the protected health information has compromised. You will be notified without unreasonable delay and no later than 60 days after discovery of the breach. Such notification will include information about what happened and what can be done to mitigate any harm.
- Right to a paper copy of this Notice of Privacy Practices, even if you have agreed to accept this Notice of Privacy Practices electronically. To obtain such a copy, please contact the Privacy Contact Person at the end of this Notice of Privacy Practices; and,
- You may, without risk of retaliation, file a complaint as to any violation by us of your privacy rights with us (by submitting inquiries to our Privacy Contact Person at our office address) or the United States Secretary of Health and Human Services (which must be filed within 180 days of the violation).
We have the following duties under the privacy rules:
- By law, to maintain the privacy of protected health information and to provide you with this notice setting forth our legal duties and privacy practices with respect to such information;
- To abide by the terms of this Notice of Privacy Practices that is currently in effect; and,
- To advise you of our right to change the terms of this Notice of Privacy Practices and to make the new notice provisions effective for all protected health information maintained by us, and that if we do so, we will provide you with a copy of the revised Notice of Privacy Practices.
Please note that we are not obligated to:
- Honor any request by you to restrict the use or disclosure of your protected health information;
- Amend your protected health information if, for example, it is accurate and complete; or,
- Provide an atmosphere that is totally free of the possibility that your protected health information may be incidentally overheard by other patients and third parties.
This Notice of Privacy Practices is effective as of the date of your signature. If you have any questions about the information in this Notice of Privacy Practices, please ask for our Privacy Contact Person or direct your questions to this person at our office address.
Privacy Contact Person:
103 O’Fallon Commons Dr.
Prior to commencing your orthodontic treatment, you should review, sign and date this form.
Your protected health information (i.e., individually identifiable information such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used in connection with your treatment, payment of your account or health care operations (i.e., performance reviews, certification, accreditation and licensure).
You have the right to review our office’s Notice of Privacy Practices prior to signing this Consent, a copy of which was given to you with this Consent.
You have the right to request restrictions on the use of your protected health information. However, we are not required to, and may not, honor your request.
We may amend the Notice of Privacy Practices at any time. If we do, we will provide you with a copy of the changes, and the changes may not be implemented prior to the effective date of the revised Notice of Privacy Practices. You may revoke this Consent at any time in writing. However, such revocation will not be effective to the extent that any action has been taken in reliance on this Consent.
Thank you for your cooperation. Please let us know if you have any questions.