 The
text of the Notice is below. If you wish, you may download the form
in Adobe Acrobat PDF format by clicking on the image to the right.
You may then print and read the form in its original format.
To view
and print the document, you'll need Adobe Acrobat Reader on your
computer. You may click on the Acrobat logo button to download
the software.
James
D. Thomas, DDS, P.C.
NOTICE
OF PRIVACY PRACTICES
THIS
NOTICE DESCRIBES HOW YOUR PROTECTED HEALTH INFORMATION MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE
REVIEW THIS CAREFULLY.
THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
OUR
OBLIGATION TO OUR PATIENTS:
We
are required by 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 that are described in this
Notice while it is in effect. This notice takes effect April
23, 2003, and will remain in effect until we replace it. You may
request a copy of our Notice at any time. For more information
about out 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, dentist,
or other healthcare provider (such as a specialist we refer you
to) providing treatment to you. Communication with other providers
is key to a successful outcome of your treatment.
Payment: We
submit claims to insurance carriers for your treatment electronically
and disclose your health information to obtain payment for services
we provide to you. We provide information to them regarding previous
and current treatment. We may also tell an insurance company about
future care in order to get prior approval or an estimate of your
benefits.
Healthcare
Operations: We may use and disclose your health information
in connection with our healthcare operations. This includes
assessment/review of our patient service, procedures, and improvement
activities, evaluating the competence, qualifications and performance
of our staff and licensed healthcare providers, conducting training
programs, accreditation, certification, licensing or credentialing
activities. From time to time students may be in our office
to observe or assist for educational purposes. We ask our
patients to inform us of their arrival by signing in on the sheet
at the front desk.
Michigan
Dental Patient Consent Law: We are required by Michigan law
(MCLA 333.16648) to obtain your written consent prior to making
certain disclosures of your health information.
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 of 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. We will disclose health information and treatment
options only to parents or guardians of minor children unless
you give us prior written authorization to disclose to another
party.
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 judgement 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 may notify our patients via mail
about new dental procedures or products we have available. We
do not share patient names or addresses with any other businesses
for their marketing purposes.
Required
by Law: We may use or disclose your health information when
we are required to do so by law. For example, 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 general public’s health
or safety.
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
inmates. We may release information to a coroner, funeral
director or medical examiner to identify a deceased person or as
necessary to carry out their duties. If you are involved in
a lawsuit, we may disclose healthcare information about you in response
to a subpoena, discovery request, or court order.
Appointment
Reminders: We may use or disclose your health information
to provide you with appointment reminders (such as voicemail messages,
answering machine, postcards, or messages left with other members
of your family).
YOUR
RIGHTS AS A PATIENT:
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
$0.50 for each page, $20 per hour for staff time to 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 our 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 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).
Alternative
Communication: You have the right to request that we communicate
with you about your health information by alternative means or
to alternative locations, i.e. you may request that we contact
you only at your office. You must make your request in writing.
Your request must specify where we should contact you, and provide
satisfactory explanation how payment 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 include why the information
should be amended.) We may deny your request under certain
circumstances such as the information was not created by our practice
or is accurate and complete as recorded.
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 believe 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
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 their address to file your complaint with
them upon request.
We
support your right to the privacy of your health information. We
will not retaliate in any way, penalize, or discriminate against
you if you choose to file a complaint with us or with the U.S. Department
of Health and Human Services.
We
reserve the right to change our privacy practices and the terms
of this Notice at any time, provided such changes are legally permitted.
This is effective for all health information that we have about
you, 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. We will always have a current notice posted
in our reception area.
Contact
Officer: Dr. James D. Thomas
Telephone: (989) 872-3870 (office) – (989) 872-4582 (fax)
Address: 6240 Hill Street, Cass City, MI 48726....
|
