ALL FAMILY DENTAL
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
We are required by applicable federal and state law to maintain the privacy
of your health information. We are also required 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 that are
described in this Notice while it is in effect. This Notice takes effect
04/14/2003, 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 changes are permitted by applicable
law. 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 healthcare operations. For example:
Treatment: We may use or disclose your health information to a physician
or other healthcare provider providing treatment for you.
Payment: We may use and disclose your health information to obtain payment
for services we provide to you.
Healthcare Operations: We may use and disclose your health information
in connection with our healthcare operations. Healthcare operations include
quality assessment and improvement activities, reviewing the competence
or qualifications of healthcare professionals, evaluating practitioner
and provider performance, conducting training programs, accreditation,
certification, licensing or credentialing activities.
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 you 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 identifying 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.
Required by Law: We may use or disclose your health information when we
are required to do so by law.
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
official having lawful custody of protected health information of inmate
or patient under certain circumstances.
Appointment Reminders: We may use or disclose your health information
to provide you with appointment reminders (such as voicemail messages,
postcards, or letters).
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 obtain a form to request access by
using the contact information listed at the end of this Notice. We will
charge you a reasonable cost-based fee for expenses such as copies and
staff time. You may also request access by sending us a letter to the
address at the end of this Notice. If you request copies, we will charge
you $1.05 for each page, $13.79 per hour for staff time to locate and
copy your health information, and postage if you want the copies mailed
to you. 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 will 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 a full explanation of our fee structure.)
Disclosure Accounting: 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, but not before April 14,
2003. 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 restriction
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).
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 it must explain why the information
should be amended.) We may deny your request under certain circumstances.
Electronic Notice: If you receive this Notice on our Web site or by electronic
mail (e-mail), you are entitled to receive this Notice in written form.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions
or concerns, please contact us.
If you are concerned that we may have violated your privacy rights, or
you disagree with a decision we made about access to your health information
or in response to a request you made to amend or restrict the use or disclosure
of your health information or to have us communicate with you by alternative
means or at alternative locations, you may complain to us using the contact
information listed at the end of this Notice. You may also 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 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.
Contact Officer: Bart Schultz ___________________________________________________________________
Telephone: 651-731-1241_____________________________
Fax: 651-731-3601___________________________________
E-Mail: __________________________________________________________________________________________
Address: 1075 Hadley Ave. N. Oakdale, MN 55128________________________________________________________
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