HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)

NOTICE OF PRIVACY PRACTICES

(Effective April 1, 2012)
Patient First Name:
Last Name:
THIS NOTICE DESCRIBES HOW MEDICAL/DENTAL INFORMATION ABOUT YOU/YOUR CHILD (OR OTHER PERSON YOU MAY BE LEGALLY RESPONSIBLE FOR) MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.


The law requires us to keep your dental records confidential and to provide you with this Notice of Privacy Practices describing how we may use and disclose your health information, including your dental history, symptoms, examination, diagnoses and treatment plans, to carry out treatment, payment and health care operations and for other purposes that are allowed or required by law. It also describes your rights to review and control the use and disclosure of your health information.
We are required to follow the privacy practices described in this Notice. We may change our privacy practices at any time. The revised privacy practices will be set forth in a revised Notice and will be effective for all health information that we maintain at that time. Upon your request, we will provide you with a copy of the most recent Notice. A current copy of our Notice of Privacy Practices will be posted in our office in a visible location at all times.
  1. Permitted Uses and Disclosures. The law allows us to use and disclose your health information for treatment, payment and health care operations.

    • Treatment means the provision, coordination and management of your health care and any related services, including consultations.

    • Payment means the activities we undertake to obtain reimbursement for the health care provided to you, including billing, collections, claims management, determinations of eligibility and coverage and other utilization review activities. For example, we may need to provide information to a third party about your health condition to determine whether a proposed treatment will be covered or to obtain payment.

    • Healthcare Operations means the support functions of our Practice, which include, but are not limited to, quality assessment and improvement activities, reviewing the quality of care provided by your providers, training of personnel and medical or dental students, licensing, and conducting or arranging for other business activities

  2. Other Uses and Disclosures of Health Information. In addition to using and disclosing yourinformation for treatment, payment and health care operations, we may use your health information in the following ways:

    • We may contact you (by automated telephone reminder, e-mail, U.S. mail or text message) to provide appointment reminders or updates on treatment options.

    • We may disclose your health information to your family or friends or any other individual identified by you, if such information is directly related to such person’s involvement in your care.

    • When permitted by law, we may use or disclose your health information in coordination with private entities authorized by law or by charter to assist in disaster relief efforts.

    • Subject to applicable law, we may make incidental uses and disclosures of your health information. Incidental uses and disclosures are by-products of otherwise permitted uses or disclosures which are limited in nature and cannot be reasonably prevented.

    • We may use or disclose your health information for research purposes, subject to the requirements of applicable law. For example, a research project may involve comparisons of the health and recovery of all patients who received a particular treatment. All research projects are subject to a special approval process, which balances research needs with a patient’s need for privacy. When required, we will obtain a written authorization from you prior to using your health information for research.

    • We will use or disclose your health information when required to do so by applicable law.

  3. Special Situations. We may use or disclose your health information in the following situations as allowed or required by law:

    • Required By Law. We may use or disclose your health information if we are legally required to do so. We will limit the use or disclosure to that required by such law.

    • Public Health. We may disclose your health information to a public health authority for purposes of controlling disease, injury or disability. We may also disclose your health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.

    • Communicable Diseases. We may disclose your 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.

    • Health Oversight. We may disclose health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include, but are not limited to, government agencies that oversee the health care system, government.

    • Abuse or Neglect. We may disclose your 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 health information to the governmental entity or agency authorized to receive such information if we believe that you have been a victim of abuse, neglect or domestic violence. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

    • Food and Drug Administration. We may disclose your health information to a person or company as required by the Food and Drug Administration (“FDA”) for purposes relating to the quality, safety or effectiveness of FDA regulated products or activities.

    • Legal Proceedings. We may disclose 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), and in certain conditions, in response to a subpoena, discovery request or other lawful process.

    • Law Enforcement. We may disclose health information, so long as applicable legal requirements are met, to law enforcement officials, for law enforcement purposes.

    • Coroners, Funeral Directors and Organ Donation. We may disclose health information to a coroner or medical examiner for identification purposes, to determine cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out his/her duties. Health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.

    • Research. We may disclose your health information to researchers when their research has been approved by a privacy board or an institutional review board.

    • Criminal Activity. Consistent with applicable federal and state laws, we may disclose your 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.

    • Military Activity and National Security. When the appropriate conditions apply, we may use or 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 services. We may also disclose your health information to authorized federal officials for conducting national security and intelligence activities, including providing protective services to the President of the United States or others.

    • Employers. We may disclose to your employer health information obtained in providing medical or dental services to you at the request of your employer for purposes of conducting an evaluation relating to medical surveillance of the workplace or determining whether you have a work-related illness or injury when such medical or dental services are needed by the employer to comply with certain legal requirements.

    • Correctional Institutions. If you are an inmate or in legal custody, we may disclose to the correctional institution or law enforcement official having legal custody of you, certain health information if necessary for health and safety purposes.

    • Workers’ Compensation. Your health information may be disclosed by us as authorized to comply with workers’ compensation laws and other similar legally established programs.

    • Compliance. Under the law, we must make disclosures of health information to the Secretary of the Department of Health and Human Services to enable it to investigate or determine our compliance with the requirements of the privacy laws.

  4. Written Authorization. Any uses and disclosures of your health information for purposes other than as described above will be made only with your written authorization.

  5. Your Rights. Following is a brief description of your rights with regard to your health information.

    1. Access. You have the limited right, subject to certain grounds for denial, to look at all of your health information that we keep except for the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and certain laboratory information restricted by federal law. You also have the limited right, subject to certain grounds for denial, to obtain copies of that health information you have a right to look at. Our office may charge you a reasonable fee for copying, mailing, labor and supplies associated with your request. Any request for access to or copies of your health information must be in writing and provided to our Privacy Officer. If your request for access to or copies of your health information is denied, you may, depending on the circumstances, have a right to have a decision to deny access reviewed. We will provide you, in writing, with our reasons for denial of access and, if, by law, you are allowed to have such denial reviewed, we will provide you with instructions for having a denial of access reviewed.

    2. Restrictions. You may ask us to restrict the use or disclosure of any part of your health information to carry out treatment, payment or healthcare operations. You may also request that any part of your health information not be disclosed to family, relatives or friends who may be involved in your care or to notify them of your location, general condition or death. In addition, you may request that we restrict the use and disclosure of your health information for disaster relief efforts. Your request must be in writing, addressed to our Privacy Officer and state the specific restriction requested and to whom you want the restriction to apply. If you are not present or able to express an objection or request a restriction to such use or disclosure, then your provider may, using the provider’s professional judgment, determine whether the use or disclosure is in your best interest. We are not required to agree to a restriction that you may request. If your provider believes it is in your best interest to permit use and disclosure of your health information, your health information will not be restricted. If your provider does agree to the requested restriction, we may not use or disclose your health information in violation of that restriction unless there is an emergency. We may terminate our agreement to restrict uses and disclosures of your health information by providing you with written notice of such; provided, however, that our termination shall only be effective with respect to health information created or received after we have given you notice of termination of the restriction.

    3. Confidential Communication. You have the right to request that we send your health information to you by alternative means or to an alternative location. We will accommodate reasonable requests. We may condition this accommodation by having you sign an authorization, asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Your request must be in writing, addressed to our Privacy Officer, and state the accommodations you are requesting.

    4. Amendments. You may request an amendment of your health information that we maintain. Such request must be in writing and provided to our Privacy Officer. If we deny your request for amendment, you have the right to file a statement of disagreement that will become part of your health information. If you file a statement of disagreement, we reserve the right to respond to your statement. You will receive a copy of any response we make and any such response will become part of your health information.

    5. Accounting of Disclosures. You have the right to receive an accounting of certain disclosures we have made, if any, of your health information. This right applies to disclosures made on and after April 1, 2012 for purposes other than (i) to carry out treatment, payment and health care operations as provided above, unless such disclosure is made through an electronic health record, in which case, the law may allow an accounting of disclosures made for a period of three (3) years prior to the request for an accounting; (ii) disclosures made to you; (iii) disclosures to a facility directory; (iv) disclosures to family members or friends involved in your care or for notification purposes; or (v) disclosures pursuant to an authorization. The right to receive this information is subject to certain exceptions, restrictions and limitations. Your request for an accounting must be in writing, addressed to our Privacy Officer.

    6. Electronic Notice. If you receive a copy of this Notice on our website or by e-mail, you have the right to obtain a paper copy from us upon request.

  6. Complaints. You may complain to us or to the Secretary of Health and Human Services if you believe we have violated your privacy rights. To complain to us, you may send our Privacy Officer a letter describing your concerns to the address found below. We respect your privacy and support any efforts to protect the privacy of your health information. We will not retaliate against you for filing a complaint.

  7. Privacy Officer Contact Information. If you have any questions about this Notice, you may contact our Privacy Officer by telephone, e-mail, facsimile, or mail at the address set forth below. If, however, you want to exercise any of your rights pursuant to this Notice of Privacy Practices or have a complaint, such action must be in writing and faxed or mailed to our Privacy Officer at the address set forth below.
Hulme Orthodontics
ATTN: PRIVACY
OFFICER 1773 Dominican Way
Santa Cruz, CA 95065
(831) 475-5500 Phone
(831) 475-0307 Facsimile
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