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.
Fusion Dental Implants Club | Galleria Oral and Maxillofacial
Surgery The Health Insurance Portability and Accountability Act of
1996 (HIPAA) requires that health providers keep your medical and
dental information private. The HIPAA Privacy Rule states that
health providers must also post in a clear and prominent location,
privacy practices described are currently 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 law. If changes
office and provided to patients. You may request a copy of our
Notice at any time. Additional information may be obtained from the
HIPAA Coordinator listed in our written HIPAA Plan.
USES AND DISCLOSURES OF HEALTH INFORMATION
The following describes how information about you may be used in
this dental office:
Treatment Services: We may use or disclose your health information
to all of our staff members, other dentists, your physicians, and
or other health care providers taking care of you.
Payment and Health Care Operations: We may use and disclose your
health information to obtain payment for services we provide to
you, to participate in quality assurance, disease management,
training, licensing, and certification programs. Upon your written
request, we will not disclose to your health insurer any services
paid by you out of pocket.
Marketing/Fundraising: We will not use your health information for
marketing or fundraising purposes without your written consent.
You can opt out of receiving information about our marketing or
fundraisers. We will not sell your health information without
your explicit authorization.
Appointment Reminders: We may use or disclose your health
information to provide you with appointment reminders such as
voicemail messages, email, postcards, or letters.
Legal Requirements: We may disclose your health information when
required to do so by law.
Abuse or Neglect: If abuse or neglect is reasonably suspected, we
may use of disclose your health information to the appropriate
National Security: When required, we may disclose military
personnel health information to the Armed Forces. Information may
be given to authorized federal officials when required for
intelligence and national security activities. Health information
for inmates in custody of law enforcement may be provided to
Family Members, Friends, and Others Involved in Care: At your
request, we may disclose your health information to a family
member or other person if necessary to assist with your treatment
and/or payment for services. Based on our judgment and as per
164.522(a) of HIPAA we may disclose your information to these
persons in the event of an emergency situation. We also may make
information available so that another person may pick up filled
prescriptions, medical supplies, records, or x-rays for you. Your
information may be disclosed to assist in notifying a family
member, caregiver, or personal representative of your location,
condition, or death.
Business Associates: Some services in our organization are
provided through contacts with business associates. Examples
include practice management software representatives, accountants,
answering service personnel, etc. When these services are
contracted, we may disclose your health information to our
business associates so that they can perform the job we have asked
them to do and bill you or your third-party payer for services
rendered. All of our business associates are required to safeguard
your information and to follow HIPAA Privacy Rules.
Workers’ Compensation: We may release medical information about
you for workers’ compensation or similar programs. These programs
provide benefits for work-related injuries or illnesses.
Research: We may use or disclose medical information to
researchers when an institution’s review board or special privacy
board has reviewed the proposed study and established protocols to
ensure the privacy of the health information used in their
research and determined that the researcher does not need to
obtain your authorization prior to using your medical information
for research purposes.
Public Health Activities: We may disclose medical information for
public health activities, to include the following: to prevent or
control disease, injury, or disability; to report reactions with
medications or problems with products, to notify people of recalls
of products they may be using; to notify a person who may have
been exposed to a disease or who may be at risk for contracting or
spreading a disease of condition; to notify the proper government
authority if we believe a patient has been the victim of abuse,
neglect, or domestic violence (when required by law).
Other Authorizations: 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.
Breach Notification: We will notify you any time your PHI may have
been compromised through unauthorized acquisition, access, use or
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
We will charge you a reasonable cost-based fee for expenses such
as copies. If you request X-Rays, there will be a fee for any
copies of films. You are not entitled to originals, only copies.
Postage will be added if copies are to be mailed. If you prefer,
we will prepare a summary or an explanation of your health
information for a fee. Details of all fees are available from the
Accounting of Disclosures: 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. 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 will keep your information confidential from your
health plans if you pay in cash, at your request. In some
instances, we may not be 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 must explain
the reason for the amendment.) We may deny your request under
QUESTIONS AND COMPLAINTS
questions or concerns, please contact us. If you have concerns
relating to a perceived violation of your privacy rights, to access
to your health information, to amending or restricting the use or
disclosure of your health information, or to requesting alternative
means of communication, you may contact us using the contact
information listed at the end of this Notice. You also may submit a
written complaint to the Department of Health and Human Services
(HHS). We will provide you with the HHS address 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 HHS.
Schedule Your First Complimentary Consultation and CT-Scan with one of our treatment coordinators