New Patient Form Acknowledgement of Policies
Notice of Privacy Practices Comprehensive Family Dentistry Responsibilities
Under the Health Insurance Portability and Accountability Act of 1996 (HIPPA), Comprehensive Family Dentistry must take steps to protect the privacy of your “protected health information” (PHI.) PHI includes information that we have created or received regarding your health or payment for your health. It includes both your medical records and personal information such as your name, social security number, address, and phone number.
Under federal law, we are required to:
- Protect the privacy of your PHI. All of our employees and Dr. Deborah Kilgore are required to maintain the confidentiality of PHI and receive appropriate training.
- Provide you with this Notice of Privacy Practices explaining our duties and practices regarding your PHI.
- Follow the practices and procedures set forth in the Notice. Uses and disclosures of your protected health information by Comprehensive Family Dentistry that do NOT require your authorization Comprehensive Family Dentistry uses and discloses PHI in a number of ways connected to your treatment, payment for your care, and our health care operations. Some examples of how we may use or disclose your PHI without your authorization are listed below. We may use or disclose your protected health information without your authorization as follows in relation to your health care and treatment:
- To our dentist, hygienists, assistants, and others involved in your health and dental care or preventive care.
- To our different departments to coordinate such activities as prescriptions, lab work, and X-rays.
- To other health care providers treating you who are not on our staff such as dentists and specialists. For example, if you are being treated for a dental trauma, we may share your PHI among your primary physician, an oral surgeon, and an endodontic so they can provide proper care. We may use or disclose your protected health information without your authorization as follows in relations to payment:
- To administer your health benefits policy or contract.
- To bill you for health care we provide.
- To pay others who provided care to you.
- To other organizations and providers for payment activities unless disclosure is prohibited by law. We may use or disclose your protected health information without your authorization as follows in relation to health care operations:
- To administer and support our business activities or those of other health care organizations (as allowed by law) including providers and plans. For example, we may use your PHI to review and improve the care you receive, to provide training, and to help decide what rates to charge.
- To other individuals (such as consultants and attorneys) and organizations that help us with our business activities. (Note: if we share your PHI with other organizations for this purpose, they must agree to protect your privacy.) We may use or disclose your protected health information without your authorization for legal and/or governmental purposes in the following circumstances:
- Required by law – When we are required to do so by the state and federal law, including workers’ compensation laws.
- Public health and safety – To an authorized public health authority or individual to:
- Protect public health and safety
- Prevent or control disease, injury, or disability.
- Report vital statistics such as births or deaths.
- Investigate or track problems with prescription drugs and medical devices. (Food and Drug Administration)
- Abuse or neglect – To government entities authorized to receive reports regarding abuse, neglect, or domestic violence.
- Oversight agencies – To health oversight agencies for certain activities such as audits, examinations, investigations, inspections, and licensures.
- Legal proceedings – In the course of any legal proceeding in response to an order of a court or administrative agency and, in certain cases, in response to a subpoena, discovery request, or other lawful process.
- Law enforcement – to law enforcement officials in limited circumstances for law enforcement purposes. For example disclosures may be made to identify or locate a suspect, witness, or missing person; to report a crème; or to provide information concerning victims of crimes.
- Military activity and national security – to the military and to authorized federal officials for national security and intelligence purposes or in connection with providing protective services to the president of the United States. We may also use or disclose your protected health information without your authorization in the following miscellaneous circumstances:
Family and friends – to a member of your family, a relative, a close friend – or any other person you identify who is directly involved in your health care – when you are either not present or unable to make a health care decision for yourself and we determine that disclosure is your best interest. For example, we may disclose PHI to a friend who brings you in for an emergency visit.
Appointment reminders – To you (or your representative), to remind you in writing (including postcards) or by phone/voicemail that you have a dental care appointment with us. For example, phone messages may be left with any individual answering the phone line of a number that you have provided us. We will assume you agree to this type of disclosure unless you specifically ask us to communicate with you through a different method as described later in the notice. Treatment alternative and plan description – To communicate with you (in person, by phone, by voicemail, by mail, or by other means of communication) about treatment services, options, or alternatives, as well as health-related benefits or services that may be of interest to you, or describe our health plan and providers to you.
Coroners, funeral directors, and organ donation – To coroners, funeral directors, and organ donation organizations as authorized by law. Disaster relief – To an authorized public or private entity for disaster relief purposes. For example, we might disclose your PHI to help notify family members of your location or general condition.
Threat to health or safety – To avoid a serious threat to the health or safety of yourself and others.
Uses and disclosures of your protected health information by Comprehensive Family Dentist that require us to obtain your authorization Except in the situations listed in the sections above, we will use and disclose your PHI only with your written authorization. In some situations, federal and state laws provide special protections for specific kinds of PHI and require authorization from you before we can disclose that specially protected PHI. In these situations, we will contact you for the necessary authorization. If you have questions about these laws, please contact the Privacy Office at 252-637-1919. If you sign an authorization you may revoke it at any time in writing, although this will not affect information that we disclosed before you revoked the authorization. If you would like to ask us to disclose your PHI, please contact the Privacy Office at 252-637-1919 for an authorization form.
Your rights regarding your protected health information
Note: You may exercise any of the rights described below, or ask questions about these rights, by contacting the Privacy Office at 252-637-1919. You have the right to:
- Request restrictions by asking that we limit the way we use or disclose your PHI for treatment, payment, or health care operations. You may also ask that we limit the information we give to someone who is involved in your care, such as family or friend. Please note that we are not required to agree to your request. If we do agree, we will honor your limits unless it is an emergency situation.
- Ask that we communicate with you by another means. For example, if you want us to communicate with you at a different address we can usually accommodate that request. We may ask that your make your request to us in writing. We will agree to reasonable requests.
- Request a copy of your PHI. We may ask you to make this request in writing and we may charge a reasonable fee for the cost of producing and mailing copies. In certain situations we may deny your request and will tell you why we are denying it. In some cases you may have the right to ask for a review of our denial.
- Ask us to amend PHI about you that we used to make decisions about you. Your request for an amendment must be in writing and provide the reason for your request. In certain cases we may deny your request, in writing. You may respond by filing a written statement of disagreement with us and ask that the statement be included with your PHI.
- Request a paper copy of this Notice. Changes to privacy practices Comprehensive Family Dentistry may change the terms of this Notice at any time. The revised Notice would apply to all PHI that we maintain. If we change any of the practices described in this Notice, we will post the revised Notice on patient accessible web sites and at Comprehensive Family Dentistry. Questions and complaints If you have any question about this Notice or would like an additional copy, please contact the Privacy Office at 252-637-1919. If you think that we may have violated your privacy rights or you disagree with a decision we made about access to your PHI, you may file a written complaint with Comprehensive Family Dentistry, Custodian of Records, Privacy Officer, 1312 Commerce Dr, New Bern, NC 28562. For more information on how to file a written complaint, call the Privacy Office at 252-637-1919. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. You will not be penalized if you file a complaint about our privacy practices with us or with Health and Human Services. You may request and be provided with a paper copy of this policy from and member of our staff.