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 (
04/13/2003
), 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 to 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 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.
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,
xrays, 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 $1.00 for each page, $10.00 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 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. {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 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.
Contact Officer: Tracy Cox
Telephone: (504) 525-9990 Fax: (504) 525-9050
E-mail: tracy@cbddentalcare.com
Address:
818
Perdido Street
,
New
Orleans
LA
70112
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