OF PRIVACY PRACTICES
DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Insurance Portability & Accountability Act of 1996 (HIPAA) requires
all health care records and other individually identifiable health
information used or disclosed to us in any form, whether electronically,
on paper, or orally, be kept confidential. This federal law gives you,
the patient, significant new rights to understand and control how your
health information is used. HIPAA provides penalties for covered entities
that misuse personal health information. As required by HIPAA, we have
prepared this explanation of how we are required to maintain the privacy
of your health information and how we may use and disclose your health
specific written authorization, we are permitted to use and disclose
your health care records for the purposes of treatment, payment and
health care operations.
means providing, coordinating, or managing health care and related
services by one or more health care providers. Examples of treatment
would include crowns, fillings, teeth cleaning services, etc.
Payment means such activities as obtaining reimbursement for services,
confirming coverage, billing or collection activities, and utilization review.
An example of this would be billing your dental plan for your dental services.
Health Care Operations include the business aspects of running our practice,
such as conducting quality assessment and improvement activities, auditing functions,
cost-management analysis, and customer service. An example would include a periodic
assessment of our documentation protocols, etc.
your confidential information may be used to remind you of an appointment
(by phone or mail) or provide you with information about treatment
alternatives or other health-related services. Any other uses and disclosures
will be made only with your written authorization. You may revoke such
authorization in writing and we are required to honor and abide by
that written request, except to the extent that we have already taken
actions relying on your authorization.
certain rights in regards to your protected health information, which
you can exercise by presenting a written request to our Privacy Officer
at the practice address listed below:
right to request restrictions on certain uses and disclosures of protected
health information, including those related to disclosures to family
members, other relatives, close personal friends, or any other person
identified by you. We are, however, not required to agree to a requested
restriction. If we do agree to a restriction, we must abide by it unless
you agree in writing to remove it.
The right to request to receive confidential communications of protected
health information from us by alternative means or at alternative locations.
The right to access, inspect and copy your protected health information.
The right to request an amendment to your protected health information.
The right to receive an accounting of disclosures of protected health
information outside of treatment, payment and health care operations.
The right to obtain a paper copy of this notice from us upon request.
required by law to maintain the privacy of your protected health information
and to provide you with notice of our legal duties and privacy practices
with respect to protected health information.
is effective as of April 14, 2003 and we are required to abide by the
terms of the Notice of Privacy Practices currently in effect. We reserve
the right to change the terms of our Notice of Privacy Practices and
to make the new notice provisions effective for all protected health
information that we maintain. Revisions to our Notice of Privacy Practices
will be posted on the effective date and you may request a written
copy of the Revised Notice from this office.
the right to file a formal, written complaint with us at the address
below, or with the Department of Health & Human Services, Office
of Civil Rights, in the event you feel your privacy rights have been
violated. We will not retaliate against you for filing a complaint.
information about our Privacy Practices, please contact:
115 Rainbow Drive
Madison, AL 35758
information about HIPAA or to file a complaint:
The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201