|
YOUNG DENTAL CARE,
LTD.
NOTICE OF PRIVACY PRACTICES
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. THE PRIVACY OF YOUR HEALTH
INFORMATION IS IMPORTANT TO US.
OUR LEGAL DUTY
Federal
and state law requires us to maintain the privacy of
your health information. That law also requires us to
give you this notice about our privacy practices, our
legal duties, and your rights concerning your health
information. We must follow the privacy practices we
describe in this notice while it is in effect. This
notice takes effect April 14, 2003, and will remain in
effect until we replace it.
We
reserve the right to change our privacy practices and
the terms of this notice at any time, provided such
applicable law permits the changes. We reserve the right
to make the changes in our privacy practices and the new
terms of our notice effective for all health information
that we maintain, including 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.
You 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 DISCLOSURES
OF HEALTH INFORMATION
We use
and disclose health information about you for treatment,
payment, and health care operations. For example:
Treatment:
We may use your health information for treatment or
disclose it to a dentist, physician or other health care
provider providing treatment to you.
Payment:
We may use and disclose your health information to
obtain payment for services we provide to you. We may
also disclose your health information to another health
care provider or entity that is subject to the federal
Privacy Rules for its payment activities.
Health
Care Operations:
We may use and disclose your health information for our
health care operations. Health care operations include
quality assessment and improvement activities, reviewing
the competence or qualifications of health care
professionals, evaluating practitioner and provider
performance, conducting training programs,
accreditation, certification, licensing, or
credentialing activities. We may disclose your health
information to another health care provider or
organization that is subject to the federal privacy
rules and that has a relationship with you to support
some of their health care operations. We may disclose
your information to help these organizations conduct
quality assessment and improvement activities, review
the competence or qualifications of health care
professionals, or detect or prevent health care fraud
and abuse.
On Your
Authorization:
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
uses 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 may disclose your health information to a family
member, friend or other person to the extent necessary
to help with your health care or with payment for your
health care. Before we disclose your health information
to these people, we will provide you with an opportunity
to object to our use or disclosure. If you are not
present, or in the event of your incapacity or an
emergency, we will disclose your medical information
based on our professional judgment of whether the
disclosure would be in your best interest. We may 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. We may use or
disclose information about you to notify or assist in
notifying a person involved in your care, of your
location and general condition.
Appointment Reminders:
We may use or disclose your health information to
provide you with appointment reminders (such as
voicemail messages, postcards, or letters.)
Disaster
Relief:
We may use or disclose your health information to a
public or private entity authorized by law or by its
charter to assist in disaster relief efforts.
Public
Benefit:
We may
use or disclose your medical information as authorized
by law for the following purposes deemed to be in the
public interest or benefit:
·
as
required by law;
·
for
public health activities, including disease and vital
statistic reporting, child abuse reporting, FDA
oversight, and to employers regarding work-related
illness or injury;
·
to
report adult abuse, neglect, or domestic violence;
·
to
health oversight agencies;
·
in
response to court and administrative orders and other
lawful processes;
·
to law
enforcement officials pursuant to subpoenas and other
lawful processes, concerning crime victims, suspicious
deaths, crimes on our premises, reporting crimes in
emergencies, and for purposes of identifying or locating
a suspect or other person;
·
to
coroners, medical examiners, and funeral directors;
·
to an
organ procurement organizations;
·
to avert
a serious threat to health or safety;
·
in
connection with certain research activities;
·
to the
military and to federal officials for lawful
intelligence, counterintelligence, and national security
activities;
·
to
correctional institutions regarding inmates; and
·
as
authorized by state worker's compensation laws.
PATIENT RIGHTS
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 information. You
may request access by sending us a letter to the address
at the end of this notice. If you request copies, we
will charge you a reasonable cost-based fee that may
include labor, copying costs, and postage. If you
request an alternative format, we will charge a
cost-based fee for providing your health information in
that format. If you prefer, we may-but are not required
to-prepare a summary or an explanation of your health
information for a fee. Contact us using the information
listed at the end of this notice for more information
about fees.
Disclosure Accounting:
You have the right to receive a list of instances in
which we or our business associates disclosed your
health information over the last 6 years (but not before
April 14, 2003). That list will not include disclosures
for treatment, payment, health care operations, as
authorized by you, and for certain other activities. 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. Contact us
using the information listed at the end of this notice
for more information about fees.
Restriction:
You have the right to request that we place additional
restrictions on our use or disclosure of your health
information. We are not required to agree to these
additional restrictions, but if we do, we will abide by
our agreement (except in an emergency). Any agreement we
may make to a request for additional restrictions must
be in writing signed by a person authorized to make such
an agreement on our behalf. Your request is not binding
unless our agreement is in writing.
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. You must specify in your request the
alternative means or location, and provide satisfactory
explanation how you will handle payment 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 it
must explain why we should amend the information. We may
deny your request under certain circumstances.
QUESTIONS AND
COMPLAINTS
If you
want more information about our privacy practices or
have questions or concerns, please contact us using the
information listed at the end of this notice.
If you
believe that:
·
we may
have violated your privacy rights,
·
we made
a decision about access to your health information
incorrectly,
·
our
response to a request you made to amend or restrict the
use or disclosure of your health information was
incorrect, or
·
we
should communicate with you by alternative means or at
alternative locations,
you may
contact us using the information listed below. You also
may submit a written complaint to the U.S. Department of
Health and Human Services.
We will
provide you with the address to file your complaint with
the U.S. Department of Health and Human Services 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 U.S.
Department of Health and Human Services.
YOUNG DENTAL CARE, LTD.
1132 Prairie Street
Aurora, IL 60506
630-892-8711
http://www.youngdentalcare.com
|
