Notice of Privacy


 

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.

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) requires all health care records and other individually idenfiable health informaon (protected health informaon) used or disclosed to us in any form, whether electronically, on paper, or orally, be kept confidenal. This federal law gives you, the paent, significant new rights to understand and control how your health informaon is used. HIPAA provides penales for covered enes that misuse personal health informaon. As required by HIPAA, we have prepared this explanaon of how we are required to maintain the privacy of your health informaon and how we may use and disclose your health informaon.

Without specific wrien authorizaon, we are permied to use and disclose your health care records for the purposes of treatment, payment and health care operaons.

  • Treatment means providing, coordinang, or managing health care and related services by one or more health care providers. Examples of treatment would include crowns, fillings, teeth cleaning services, etc.
  • Payment means such acvies as obtaining reimbursement for services, confirming coverage, billing or collecon acvies, and ulizaon review. An example of this would be billing your dental plan for your dental services.
  • Health Care Operaons include the business aspects of running our pracce, such as conducng quality assessment and improvement acvies, auding funcons, cost management analysis, and customer service. An example would include a periodic assessment of our documentaon protocols, etc.

In addion, your confidenal informaon may be used to remind you of an appointment (by phone or mail) or provide you with informaon about treatment opons or other health related services including release of informaon to friends and family members that are directly involved in your care or who assist in taking care of you. We will use and disclose your protected when we are required to do so by federal, state or local law. We may disclose your PROTECTED HEALTH INFORMATION to public health authories that are authorized by law to collect informaon, to a health oversight agency for acvies authorized by law included but not limited to: response to a court or administrave order, if you are involved in a lawsuit or similar proceeding, response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecng the informaon the party has requested. We will release your PROTECTED HEALTH INFORMATION if requested by a law enforcement official for any circumstance required by law. We may release your PROTECTED HEALTH INFORMATION to a medical examiner or coroner to idenfy a deceased individual or to idenfy the cause of death. If necessary, we also may release informaon in order for funeral directors to perform their jobs. We may release PROTECTED HEALTH INFORMATION to organizaons that handle organ, eye or ssue procurement or transplantaon, including organ donaon banks, as necessary to facilitate organ or ssue donaon and transplantaon if you are an organ donor.

We may use and disclose your PROTECTED HEALTH INFORMATION when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organizaon able to help prevent the threat. We may disclose your PROTECTED HEALTH INFORMATION if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authories. We may disclose your PROTECTED HEALTH INFORMATION to federal officials for intelligence and naonal security acvies authorized by law. We may disclose PROTECTED HEALTH INFORMATION to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct invesgaons. We may disclose your PROTECTED HEALTH INFORMATION to correconal instuons or law enforcement HIPAA/@Noce of Privacy Pracces.doc officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the instuon to provide health care services to you, (b) for the safety and security of the instuon, and/or (c) to protect your health and safety or the health and safety of other individuals or the public. We may release your PROTECTED HEALTH INFORMATION for workers' compensaon and similar programs.

Any other uses and disclosures will be made only with your wrien authorizaon. You may revoke such authorizaon in wring and we are required to honor and abide by that wrien request, except to the extent that we have already taken acons relying on your authorizaon.

You have certain rights in regards to your PROTECTED HEALTH INFORMATION, which you can exercise by presenng a wrien request to our Privacy Officer at the pracce address listed below:

  • The right to request restricons on certain uses and disclosures of PROTECTED HEALTH INFORMATION, including those related to disclosures to family members, other relaves, close personal friends, or any other person idenfied by you. We are, however, not required to agree to a requested restricon. If we do agree to a restricon, we must abide by it unless you agree in wring to remove it.

  • The right to request to receive confidenal communicaons of PROTECTED HEALTH INFORMATION from us by alternave means or at alternave locaons.

  • The right to access, inspect and copy your PROTECTED HEALTH INFORMATION.

  • The right to request an amendment to your PROTECTED HEALTH INFORMATION.

  • The right to receive an accounng of disclosures of PROTECTED HEALTH INFORMATION outside of treatment, payment and health care operaons.

  • The right to obtain a paper copy of this noce from us upon request.

We are required by law to maintain the privacy of your PROTECTED HEALTH INFORMATION and to provide you with noce of our legal dues and privacy pracces with respect to PROTECTED HEALTH INFORMATION.

We are required to abide by the terms of the Noce of Privacy Pracces currently in effect. We reserve the right to change the terms of our Noce of Privacy Pracces and to make the new noce provisions effecve for all PROTECTED HEALTH INFORMATION that we maintain. Revisions to our Noce of Privacy Pracces will be posted on the effecve date and you may request a wrien copy of the Revised Noce from this office.

You have the right to file a formal, wrien complaint with us at the address below, or with the Department of Health & Human Services, Office of Civil Rights, in the event you feel your privacy rights have been violated. We will not retaliate against you for filing a complaint.

For more informaon about our Privacy Pracces, please contact us at (917) 868-1552


For more informaon about HIPAA or to file a complaint:

The U.S. Department of Health & Human Services

Office of Civil Rights

200 Independence Avenue, S.W.

Washington, D.C. 20201 8776966775 (tollfree)

Location
Concierge Dental Design
26 Broadway, Suite 1303
Financial District

New York, NY 10004
Phone: 917-737-1604
Fax: 917-633-4456
Office Hours

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917-737-1604