Alliance Family Dentistry, P.C.

6140 Tutt Boulevard, Suite 140

Colorado Springs, CO 80922-3568

719-955-4023

Notice of Privacy Practices for Protected Health Information

Effective Date:  01 March 2005

This Notice describes how Medical/Dental information about you may be used and disclosed and how you can get access to this information.  Please review it carefully!

Our Legal Duty

Alliance Family Dentistry, P.C., is required by applicable federal and state law to maintain the privacy of your health information and to give you this Notice regarding our privacy practices, our legal duties and you rights concerning your health information.  We must follow the privacy practices that are described in this Notice while it is in effect. 

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 and the new terms of our Notice effective for all health information that we maintain, to include 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.

Your 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 Disclosure of Health Information

We are permitted by federal and state privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations.  Protected health information is the information we create and obtain in providing our services to you.  Such information may include documenting your symptoms, examinations, and test results, diagnoses, treatment, and applying for future care or treatment.  It also includes billing documents for those services.

Examples of Uses of Your Health Information for Treatment Purposes are:

● A staff member obtains treatment information about you and records it in a dental health record.

● During the course of your treatment, the dentist determines he will need to consult with another dental or medical specialist about your procedure.  He will share the information with such specialist and obtain his/her input as it relates to that treatment. 

Examples of Use of Your Health Information for Payment Purposes:

● We submit requests for payment to your dental insurance company.  The insurance company (or other business associate helping us process and obtain payment) requests information from us regarding dental care and treatment given.  We will provide information to them about you and the care given. 

Examples of Use of Your Information for Health Care Operations:

● We obtain services from our insurers or other business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guideline development, training programs, credentialing, medical review, legal services, and insurance.  We will share information about you with such insurers or other business associates as necessary to obtain these services.

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 indentifying 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.

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 officials having lawful custody of protected health information of inmate or patients under certain circumstances.

Appointment Reminders:

● We may use or disclose your health information to provide you with appointment reminders and confirmations (such as voicemail messages, postcards, or letters).

Other Possible Disclosures and Uses

Disaster Relief

● We may use and disclose your protected health information to assist in disaster relief efforts.

Food and Drug Administration (FDA)

● We may disclose to the FDA your protected health information relating to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.

Workers Compensation

● If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.

Employers

● We may release health information about you to your employer if we provide health care services to you at the request of your employer, and the health care services are provided either to conduct an evaluation relating to medical surveillance of the workplace or to evaluate whether you have a work-related illness or injury.  In such circumstances, we will give you written notice of such release of information to your employer.  Any other disclosures to your employer will be made only if you execute a specific authorization for the release of that information to your employer.

Law Enforcement

● We may disclose your protected health information for law enforcement purposes as require by law, such as when required by a court order, or incases involving felony prosecution, or to the extent an individual is in the custody of law enforcement.

Judicial / Administrative Proceedings

● We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your authorization, or as directed by a proper court order.

Coroners, Medical Examiners, and Funeral Directors

● We may release health information to a coroner or medical examiner.  This may be necessary, for example, to identify a deceases person or determine the cause of death.  We may also release health information about patients to funeral directors as necessary for them to carry out their duties.

Other Uses

● Other uses and disclosures, besides those identified in this Notice, will be made only as otherwise required by law or with your written authorization and you may revoke the authorization as previously provided in this Notice under “your Health Information Rights.”

Your Health Information Rights

The health and billing records we maintain are the physical property of the office.  The information in it, however, belongs to you. 

You have a right to:

● Request a restriction on certain uses and disclosures of your health information by delivering the request to our office.  We are not required to grant the request, but we will comply with any request that we grant.

● Obtain a paper copy of the current Notice of Privacy Practices for Protected Health Information (“Notice”) by making a request at our office.

● Request that you be allowed to inspect your dental record and billing record.  You may exercise this right by delivering the request to our office.  We will provide paper copies at a nominal fee to cover expenses and staff time.

● Appeal a denial of access to your protected health information, with limited exceptions.

● Request that your dental care record be amended to correct incomplete or incorrect information by delivering a request to our office.  We may deny your request if you ask us to amend information that:

● Was not created by us, unless the person or entity that created the information is no longer available to make the amendment.

● Is not part of the health information kept by or for this office.

● Is not part of the information that you would be permitted to inspect and copy; or,

● Is accurate and complete.

If your request is denied, you will be informed of the reason for the denial and will have and opportunity to submit a statement of disagreement to be maintained with your records.

● Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office.

● Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a request to our office.  An accounting will not include uses and disclosures of information for treatment, payment, or operations; disclosures or uses made to you or made at your request; uses or disclosures made pursuant to an authorization signed by you; uses or disclosures made in a facility directory or to family members or friends relevant to that person’s involvement in your care or in payment for such care; or, uses or disclosures to notify family or others responsible for your care, of your location, condition, or your death.

● Revoke authorizations that you made previously to use or disclose information by delivering a written revocation to our office, except to the extent information or action has already been taken.

If you want to exercise any of the above rights, please contact HIPAA Manager, Alliance Family Dentistry, P.C., 6140 Tutt Blvd, Suite 140, Colorado Springs, CO 80922, PHONE #, in person or in writing, during regular business hours.  She will inform you of the steps that need to be taken to exercise your rights.

Our Responsibilities

The office is required to:

● Maintain the privacy of your health information as required by law.

● Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you.

● Abide by the terms of this Notice.

● Notify you if we cannot accommodate a requested restriction or request; and,

● Accommodate your reasonable requests regarding methods to communicate health information with you.

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain.  If our information practices change, we will amend our Notice.  You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our ”Notice” or by visiting our office and picking up a copy.

To Request Information or File a Complaint

If you have questions, would like additional information, or want to report a problem regarding the handling of you information, you may contact HIPAA Manager, Alliance Family Dentistry, P.C., 6140 Tutt Blvd, Suite 140, Colorado Springs, CO 80922, PHONE #.

Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to our HIPAA manager.

You may also file a complaint by mailing it or e-mailing it to the Secretary of Health and Human Services, whose street address and e-mail address is:  Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue S.W., Room 509F, HHH Building, Washington, D.C., 20201.

● We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the office.

● We cannot, and will not, retaliate against you for filing a complaint with the Secretary of Health and Human Services.

Website

● If we maintain a website that provides information about our entity, this Notice will be on the website.