HIPAA NOTICE OF PRIVACY PRACTICES
Notice of Privacy Practices Kathleen M. Eisin, D.D.S., M.S., P.L.L.C. 6677 Crossings Drive Grand Rapids, MI 49508 This notice describes how medical information about you may be used and disclosed, and how you can gain access to this information. Please review it carefully. Protected health information (PHI), about you is maintained as a written and or/electronic record of your contacts or visits for healthcare services with our practice. Specifically, PHI is information about you, including demographic information (i.e., name, address, phone, etc.), that may identify you and relates to your past, present or future dental or physical condition and related healthcare services. Our practice is required to follow specific rules on maintaining the confidentiality of your PHI, using your information, and disclosing or sharing this information with other healthcare professionals involved in your care and treatment. This Notice describes your rights to access and control your PHI. It also describes how we follow applicable rules and use and disclose your PHI to provide your treatment, obtain payment for services you receive, manage our healthcare operations and for other purposes that are permitted or required by law. Your Rights Under The Privacy Rule Following is a statement of your rights, under the Privacy Rule, in reference to your PHI. Please feel free to discuss any questions with our staff. You have the right to receive, and we are required to provide you with a copy of this Notice of Privacy Practices- We are required to follow the terms of this notice. We reserve the right to change the terms of our notice, at any time. Upon your request, we will provide you with a revised Notice of Privacy Practices if you call our office and request a revised copy to be sent to you in the mail or ask for one at the time of your next appointment. The Notice will also be posted in a conspicuous location within the practice, and on our website: www. eisinperio.com. You have the right to authorize other use and disclosure-This means you have the right to authorize any use or disclosure of PHI that is not specified within this notice. You may revoke an authorization, at any time, in writing, except to the extent that your healthcare provider or our practice has taken an action in reliance on the use or disclosure indicated in the authorization. You have the right to request an alternative means of confidential communication – This means you have the right to ask us to contact you about dental matters using an alternative method (i.e., email, telephone), and to a destination (i.e., cell phone number, alternative address, etc.) designated by your. You must inform us in writing, using a form provided by our practice, how you wish to be contacted if other than the address/phone number that we have on file. We will follow all reasonable requests. You have the right to inspect and copy your PHI – This means you may inspect, and obtain a copy of your complete dental record. If you dental record is maintained electronically, you will have the right to request a copy in electronic format. We have the right to charge a reasonable fee for paper or electronic copies as established by professional, state, or federal guidelines. You have the right to request a restriction of your PHI – This means you may ask us, in writing, not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. If we agree to the requested restriction, we will abide by it, except in emergency circumstances when the information is needed for you treatment. In certain cases, we may deny your request for a restriction. You will have the right to request, in writing, that we restrict communication to your dental plan regarding a specific treatment or service that you, or someone on your behalf has paid for in full, out-of-pocket. We are not permitted to deny this specific type of requested restriction. You may have the right to request an amendment to your protected health information- This means you may request an amendment of your PHI, to entities or persons outside of our office. You have the right to request disclosure accountability – This means that you may request a listing of disclosures that we have made, of your PHI, to entities or persons outside of our office. You have the right to receive a privacy breach notice- You have the right to receive written notification if the practice discovers a breach of your unsecured PHI, and determines through a risk assessment that notification is required. How We May Use or Disclose Protected Health Information Following are examples of uses and disclosures of your PHI that we are permitted to make. These examples are not meant to be all inclusive, but to describe possible types of uses and disclosures. Treatment – We may use and disclose your PHI to provide, coordinate or manage your dental care and any related services. This includes the coordination or management of your dental care with a third party such as your general dentist, another dental professional, our dental laboratory, or your pharmacy. We will also disclose PHI to other Healthcare Providers who may be involved in your care and treatment. Special Notices – We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment or the need for an appointment. We may contact you by phone or other means to provide results form exams or tests and to provide you with information that describes or recommends treatment. You will have the right to opt out of such special notices, and each such notice will include instructions for opting out. Payment – Your PHI will be used, as needed, to obtain payment for your dental care services. This may activities that your dental or health benefit plan may undertake before it approves or pays for the dental care services we provide for you such as, making a determination of eligibility or coverage for benefits. To Others Involved in Your Dental Care – Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person, that you identify, your PHI that directly relates to that person’s involvement in your dental care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine it is in your best interest based on our professional judgment. We may use of disclose PHI to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care, of your general condition or death. If you are not present or able to agree or object to the use or disclosure of the PHI, then your dental provider may, using professional judgment, determine whether the discloser is in your best interest. In this case, only the PHI that is necessary will be disclosed. Other Permitted and Required Uses and Disclosures – We are also permitted to use or disclose your PHI without your written authorization for the following purposes: as required by law; for public health activities, health oversight activities, in cases of abuse or neglect; to comply with Food and Drug Administration requirements; research purposes; legal proceedings; law enforcement purposes; coroners; funeral directors; organ donation; criminal activity; military activity; national security; worker’s compensation; when an inmate in a correctional facility; and if requested by the Department of Health and Human Services in order to investigate or determine our compliance with the requirements of The Privacy Rule. Privacy Complaints You have the right to complain to us or directly to the Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying the Privacy Manager at: 616-656-0400 We will not retaliate against you for filing a complaint. Effective Date: 9/23/2013 Publication Date: 9/23/2013 This page is in development.