ABG Dental of Elkhart/Goshen
NOTICE OF PRIVACY PRACTICES
PLEASE CAREFULLY REVIEW THIS NOTICE. THIS NOTICE DESCRIBES HOW WE MAY USE AND DISCLOSE YOUR MEDICAL INFORMATION AND HOW YOU MAY GAIN ACCESS TO YOUR MEDICAL INFORMATION.
This is your Health Information Privacy Notice from ABG Dental of Elkhart. PLEASE READ IT CAREFULLY. This Notice describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is individually identifiable information about you, including demographic information, that relates to your past, present or future physical or mental health or condition and related health care services.
We are legally required to: provide this Notice to you by the Health Insurance Portability and Accountability Act (“HIPAA”), maintain the privacy of your protected health information, and abide by the terms of this Notice of Privacy Practices. For additional information concerning our HIPAA Privacy Policy, you may submit questions to us at 2549 Prairie St, Elkhart IN, 46517.
Additionally, we reserve the right to change the terms of this notice at any time. We reserve the right to make the revised or changed notice effective for protected health information we already have about you as well as any protected health information we receive in the future. The effective date of this notice and any revised or changed notice may be found on the last page. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. You may request a revised version by calling our office and requesting that a revised copy be sent to you in the mail or by asking for one at the time of your next appointment.
1. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
Your protected health information may be used and disclosed by your physician, our office staff and others outside of our offices who are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of your physician’s practice.
We protect your protected health information from inappropriate use or disclosure. Our employees, and those of companies that help us serve you, are required to comply with our requirements that protect the confidentiality of protected health information. They may look at your protected health information only when there is an appropriate reason to do so, such as to administer our services.
Examples of the main reasons for which we may use and may disclose your protected health information are below. These are examples of the types of uses and disclosures of your protected health information that your physician’s office is permitted to make. These are simply examples, and are not meant to be exhaustive.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with another provider. For example, we would disclose your protected health information, as necessary, to a home health agency or to other physicians that provides care to or may be treating you. Your protected health information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you. In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care by providing assistance with your health care diagnosis or treatment to your physician.
Payment: Your protected health information will be used and disclosed, as needed, to obtain payment for your health care services provided by us or by another provider. This may include certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you such as: making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity, and undertaking utilization review activities.
Health Care Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, fundraising activities, and conducting or arranging for other business activities.
We will share your protected health information with third party “business associates” that perform various activities (for example, billing or transcription services) for our practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.
We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. You may contact our Privacy Officer to request that these materials not be sent to you.
We may use or disclose your demographic information and the dates that you received treatment from your physician, as necessary, in order to contact you for fundraising activities supported by our office. You have the right to opt-out of communications involving fundraising. If you do not want to receive these materials, please contact our Privacy Officer and request that these fundraising materials not be sent to you and request you not be contacted in regards to our fundraising activities.
Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or Object:
We may use or disclose your protected health information in the following situations without your authorization or providing you the opportunity to agree or object. These situations include:
As Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses or disclosures.
Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. For example, a disclosure may be made for the purpose of preventing or controlling disease, injury or disability.
Childhood Immunizations: We may use or disclose your protected health information to disclose immunizations to schools required to obtain proof of immunization prior to admitting the student so long as we have and document the patient or patient’s legal representative’s “informal agreement” to the disclosure.
Communicable Diseases: We may disclose your protected 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 protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.
Abuse or Neglect: We may disclose your protected 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 protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. 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 protected health information to a person or company as required by the Food and Drug Administration for the purpose of quality, safety, or effectiveness of FDA-regulated products or activities including: to report adverse events, product defects or problems, biologic product deviations, to track products, to enable product recalls, to make repairs or replacements, or to conduct post marketing surveillance, as required.
Legal Proceedings: We may disclose protected 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), or in certain conditions in response to a subpoena, discovery request or other lawful process.
Law Enforcement: We may disclose protected health information, without your prior written authorization, under specific circumstances to law enforcement officials or for law enforcement purposes. The reasons we would disclose your protected health information to law enforcement officials or for law enforcement purposes include: (1) to comply with a court order or court- ordered warrant, subpoena, or summons issued by a judicial officer, or a grand jury subpoena; (2) to respond to an administrative request, such as from an investigative demand or written request from a law enforcement official; (3) to respond to a request for protected health information for purposes of identifying or locating a suspect, fugitive, material witness, or missing person; (4) to respond to a request for information about a victim of a crime if the victim agrees; (5) to report protected information to law enforcement in any case as required by law; (6) to alert law enforcement to the death of the individual where there is suspicion that the death has occurred as a result of criminal conduct; (7) to report protected health information that we believe in good faith to be evidence of a crime that occurred on our premises; (8) to respond to an off-site medical emergency, as necessary to alert law enforcement about criminal activity; and (9) for certain other specialized governmental law enforcement purposes, such as, but not limited to, providing information to federal officials authorized to conduct intelligence or national security activities and to respond to a request for information by a correctional institution.
Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director, as authorized by law, in order to permit the funeral director to carry out their duties. We may disclose such information in reasonable anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donation purposes.
Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.
Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected 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. We may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
Fundraising: Consistent with applicable federal and state laws, we may use or disclose to a business associate or to an institutionally related foundation, for fundraising purposes for our own benefit, the following information without your written authorization: demographic data, health insurance status, dates of patient health care services, general department of service information, treating physician information, and outcome information.
Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected 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 protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.
Workers’ Compensation: We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legally-established programs.
Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.
Uses and Disclosures of Protected Health Information Based upon Your Written Authorization:
Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization in writing at any time by contacting our Privacy Officer. If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures already made with your authorization.
Fundraising: We may seek your written authorization to use or disclose certain protected, medically related health information to filter or target our fundraising efforts. The protected health information that requires your authorization prior to use for fundraising includes, but is not limited to non-demographic information such as: diagnosis, illness, or nature of services or treatment.
Sale of Protected Health Information: We may seek your written authorization for any disclosure of your protected health information that constitutes a “sale of protected health information.” “Sale of protected health information” shall be defined as a disclosure of protected health information our organization directly or indirectly receives remuneration from or on behalf of the recipient of the protected health information in exchange for the protected health information. Such remuneration would include both financial and non-financial, in-kind benefits.
Other Permitted and Required Uses and Disclosures That Require Providing You the Opportunity to Agree or Object:
We may use and disclose your protected health information in the instances provided for below. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest.
Facility Directories: Unless you object, we will use and disclose in our facility directory your name, the location at which you are receiving care, your general condition (such as fair or stable), and your religious affiliation. All of this information, except religious affiliation, will be disclosed to people that ask for you by name. Your religious affiliation will be only given to a member of the clergy, such as a priest or rabbi.
Others Involved in Your Health Care or Payment for your Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information regarding your location, general condition, or death to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care. Finally, we may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or other individuals involved in your health care.
Marketing Communications: In the absence of authorization, we will only provide you with marketing communications under the following scenarios: 1) the physician and our office receives no compensation for the communication; 2) the communication is face-to-face; 3) the communication involves a drug or biologic the patient is currently being prescribed and the payment will not create a profit; 4) the communication involves general health promotion, rather than promotion of a specific product or service; or 5) the communication involves government or government-sponsored programs.
Out-of-Pocket Payments: Unless you object, we may disclose information about care you have paid for out-of-pocket to health plans. You have the right to request we do not disclose such information, unless the information is being disclosed for treatment purposes or in the event the disclosure is required by law.
2. YOUR RIGHTS
You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you for so long as we maintain the protected health information. You may obtain your medical record that contains medical and billing records and any other records that your physician and the practice use for making decisions about you. As permitted by federal or state law, we may charge you a reasonable cost-based fee for a copy of your records, with such fees including, but not limited to, a copy fee and/or a mailing fee.
Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and laboratory results that are subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Officer if you have questions about access to your medical record.
You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
Your physician is not required to agree to a restriction that you may request. If your physician does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You may request a restriction by contacting our Privacy Officer.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by 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. Please make this request in writing to our Privacy Officer.
You may have the right to have your physician amend your protected health information.
This means you may request an amendment of protected health information about you in a designated record set for so long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Please contact our Privacy Officer if you have questions about amending your medical record.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice. It excludes disclosures we may have made to you if you authorized us to make the disclosure, for a facility directory, to family members or friends involved in your care, or for notification purposes, for national security or intelligence, to law enforcement (as provided in the privacy rule) or correctional facilities, or as part of a limited data set disclosure. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. The right to receive this information is subject to certain exceptions, restrictions and limitations. You must make this request in writing and this request must include a time frame, which may not be longer than six (6) years and may not include dates prior to April 14, 2003.
You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.
3. BREACH NOTIFICATION:
We will notify any affected individuals following the discovery of a breach of unsecured protected health information. In the event of a breach of your protected health information, we will provide you with notice in written form by first-class mail, or alternatively, by e-mail if you have agreed to receive such notices electronically. If we have insufficient or out-of-date contact information for you, we may provide you with notice by an alternative form of written, telephone, or other notice. Such individual notification shall be provided without unreasonable delay and, in all cases, within sixty (60) days following the discovery of a breach and will include the following, to the extent possible: a breach description; a description of the information types involved in the breach; the steps you should take to protect yourself from potential harm; a description of what steps we are taking to investigate the breach, mitigate the harm, and prevent further breaches; and information on how to contact us.
4. COMPLAINTS
If you think we may have violated your privacy rights, or you disagree with a decision we made about access to your protected health information, you may file a complaint with us or to the Secretary of Health and Human Services.
You may file a complaint with us by notifying our Privacy Officer of your complaint. We will not retaliate against you for filing a complaint. To file a complaint with us, please contact our Privacy Officer by writing to us at 2549 Prairie St, Elkhart IN, 46517. All complaints must be submitted in writing. If you have questions as to how to file a complaint, please contact us at 574-389-8300.
5. EFFECTIVE DATE OF THIS NOTICE
This notice was published and becomes effective on January 2, 2017.