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JOINT NOTICE OF PRIVACY
PRACTICES THIS NOTICE DESCRIBES HOW
MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
This Notice applies to the information and records
we have about your health, health status, and the health care
and services you receive at this office. 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 April 14, 2003, and
will remain in effect until we replace it.
If you have any questions about this
Notice, complaints, or should you need to contact Western’s
Privacy Officer to comply with any provision of this Notice,
please contact: Western’s Privacy Officer, C/o Western Dental
Of Arizona, Inc., P.O. Box 14227, Orange, CA 92863, Phone:
(800) 417-4444. E-mail: PrivacyOfficer@WesternDental.com
Organizations covered by Joint Notice:
Western Dental Of Arizona, Inc. Premier Choice Dental, Inc.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION
ABOUT YOU
For Treatment We may use your health
information to provide you with medical treatment or services.
We may disclose health information about you to doctors,
dental assistants, technicians, office staff or other
personnel who are involved in taking care of you and your
health.
For example, your doctor may be performing a tooth
extraction and may need to know if you have other health
problems that could complicate your treatment. The doctor may
use your health history to decide what treatment is best for
you. The doctor may also tell another doctor about your
condition so that doctor can help determine the most
appropriate care for you.
Different personnel in our office may share information
about you and disclose information to people who do not work
in our office in order to coordinate your care, such as
phoning in prescriptions to your pharmacy, scheduling lab work
and ordering x-rays. Family members and other health care
providers may be part of your medical care outside this office
and may require information about you that we have.
For Payment We may use and disclose health
information about you so that the treatment and services you
receive at this office may be billed to and payment may be
collected from you, an insurance company or a third party. For
example, we may need to give your health plan information
about a service you received here so your health plan will pay
us or reimburse you for the service. We may also tell your
health plan about a treatment you are going to receive to
obtain prior approval, or to determine whether your plan will
cover the treatment.
For Health Care Operations We may use and
disclose health information about you in order to run the
office and make sure that you and our other patients receive
quality care. For example, we may use your health information
to evaluate the performance of our staff in caring for you. We
may also use health information about all or many of our
patients to help us decide what additional services we should
offer, how we can become more efficient, or whether certain
new treatments are effective.
Appointment Reminders We may contact you
as a reminder that you have an appointment for treatment or
medical care at the office. Treatment Alternatives We may tell
you about or recommend possible treatment options or
alternatives that may be of interest to you.
Health-Related Products and Services We
may tell you about health-related products or services that
may be of interest to you.
SPECIAL SITUATIONS
We may use or disclose health information about you without
your permission for the following purposes, subject to all
applicable legal requirements and limitations:
To Avert a Serious Threat to Health or
Safety We may use and disclose health information
about you when necessary to prevent a serious threat to your
health and safety or the health and safety of the public or
another person.
Required By Law We will disclose health
information about you when required to do so by federal, state
or local law. For example, Western Dental may disclose
information for the following purposes:
- For judicial and administrative
proceedings pursuant to legal authority;
- To report information related to
victim of abuse, neglect or domestic violence; and,
- To assist law enforcement officials in their law
enforcement duties.
Research We may use and disclose health
information about you for research projects that are subject
to a special approval process. We will ask you for your
permission if the researcher will have access to your name,
address or other information that reveals who you are, or will
be involved in your care at the office.
Organ and Tissue Donation If you are an
organ donor, we may release health information to
organizations that handle organ procurement or organ, eye or
tissue transplantation or to an organ donation bank, as
necessary to facilitate such donation and transplantation.
Military, Veterans, National Security and
Intelligence If you are or were a member of the armed
forces, or part of the national security or intelligence
communities, we may be required by military command or other
government authorities to release health information about
you. We may also release information about foreign military
personnel to the appropriate foreign military authority.
Workers' Compensation We may release
health information about you in order to comply with the law
and regulations related to workers' compensation or similar
programs. These programs provide benefits for work-related
injuries or illness.
Public Health Risks We may disclose health
information about you for public health reasons in order to
prevent or control disease, injury or disability; or report
births, deaths, suspected abuse or neglect, non-accidental
physical injuries, reactions to medications or problems with
products.
Health Oversight Activities We may
disclose health information to a health oversight agency for
audits, investigations, inspections, or licensing purposes.
These disclosures may be necessary for certain state and
federal agencies to monitor the health care system, government
programs, and compliance with civil rights laws.
Lawsuits and Disputes If you are involved
in a lawsuit or a dispute, we may disclose health information
about you in response to a court or administrative order.
Subject to all applicable legal requirements, we may also
disclose health information about you in response to a
subpoena.
Law Enforcement We may release health
information if asked to do so by a law enforcement official in
response to a court order, subpoena, warrant, summons or
similar process, subject to all applicable legal requirements.
Coroners, Medical Examiners and Funeral
Directors We may release health information to a
coroner or medical examiner to enable them to carry out their
lawful duties. This may be necessary, for example, to identify
a deceased person or determine the cause of death.
Information Not Personally Identifiable We
may use or disclose health information about you in a way that
does not personally identify you or reveal who you are.
Family and Friends We may disclose health
information about you to your family members or friends if we
obtain your verbal agreement to do so or if we give you an
opportunity to object to such a disclosure and you do not
raise an objection. We may also disclose health information to
your family or friends if we can infer from the circumstances,
based on our professional judgment that you would not object.
For example, we may assume you agree to our disclosure of your
personal health information to your spouse when you bring your
spouse with you into the exam room during treatment or while
treatment is discussed.
In situations where you are not capable of giving consent
(because you are not present or due to your incapacity or
medical emergency), we may, using our professional judgment,
determine that a disclosure to your family member or friend is
in your best interest. In that situation, we will disclose
only health information relevant to the person's involvement
in your care. For example, we may inform the person who
accompanied you to the emergency room that you suffered a
heart attack and provide updates on your progress and
prognosis. We may also use our professional judgment and
experience to make reasonable inferences that it is in your
best interest to allow another person to act on your behalf to
pick up, for example, filled prescriptions, medical supplies,
or X-rays.
OTHER USES AND DISCLOSURES OF HEALTH
INFORMATION
We will not use or disclose your health information for any
purpose other than those identified in the previous sections
without your specific, written Authorization. If you give us
Authorization to use or disclose health information about you,
you may revoke that Authorization, in writing, at any time. If
you revoke your Authorization, we will no longer use or
disclose information about you for the reasons covered by your
written Authorization, but we cannot take back any uses or
disclosures already made with your permission.
YOUR RIGHTS REGARDING HEALTH
INFORMATION ABOUT YOU
You have the following rights regarding health information
we maintain about you:
Right to Inspect and Copy You have the
right to inspect and copy your health information, such as
medical and billing records, that we use to make decisions
about your care. You must submit a written request to
Western’s Privacy Officer in order to inspect and/or copy your
health information. If you request a copy of the information,
we may charge a fee for the costs of copying, mailing or other
associated supplies. We may deny your request to inspect
and/or copy in certain limited circumstances. If you are
denied access to your health information, you may ask that the
denial be reviewed. If such a review is required by law, we
will select a licensed health care professional to review your
request and our denial. The person conducting the review will
not be the person who denied your request, and we will comply
with the outcome of the review.
Right to Amend If you believe health
information we have about you is incorrect or incomplete, you
may ask us to amend the information. You have the right to
request an amendment as long as the information is kept by
this office. To request an amendment, complete and submit a
Dental Record Amendment/Correction Form to Western’s Privacy
Officer. We may deny your request for an amendment if it is
not in writing or does not include a reason to support the
request. In addition, we may deny your request if you ask us
to amend information that:
- a) We did not create, unless the
person or entity that created the information is no longer
available to make the amendment.
- b) Is not part of the health
information that we keep.
- c) You would not be permitted to
inspect and copy.
- d) Is accurate and complete.
Right to an Accounting of Disclosures You
have the right to request an "accounting of disclosures." This
is a list of the disclosures we made of medical information
about you for purposes other than treatment, payment and
health care operations. To obtain this list, you must submit
your request in writing to Western’s Privacy Officer. It must
state a time period, which may not be longer than six years
and may not include dates before April 14, 2003. Your request
should indicate in what form you want the list (for example,
on paper, electronically). We may charge you for the costs of
providing the list. We will notify you of the cost involved
and you may choose to withdraw or modify your request at that
time before any costs are incurred.
Right to Request Restrictions You have the
right to request a restriction or limitation on the health
information we use or disclose about you for treatment,
payment or health care operations. You also have the right to
request a limit on the health information we disclose about
you to someone who is involved in your care or the payment for
it, like a family member or friend. For example, you could ask
that we not use or disclose information about a surgery you
had.
We are Not Required to Agree to Your
Request If we do agree, we will comply with your
request unless the information is needed to provide you
emergency treatment. To request restrictions, you may complete
and submit the Request For Restriction On Use/Disclosure Of
Medical Information to Western’s Privacy Officer.
Right to Request Confidential
Communications You have the right to request that we
communicate with you about medical matters in a certain way or
at a certain location. For example, you can ask that we only
contact you at work or by mail. To request confidential
communications, you may complete and submit the Request For
Restriction On Use/Disclosure Of Medical Information And/Or
Confidential Communication to Western’s Privacy Officer. We
will not ask you the reason for your request. We will
accommodate all reasonable requests. Your request must specify
how or where you wish to be contacted.
CHANGES TO THIS NOTICE
We reserve the
right to change this notice, and to make the revised or
changed notice effective for medical information we already
have about you as well as any information we receive in the
future. We will post a summary of the current notice in the
office with its effective date in the top right hand corner
and mail a copy to you.
COMPLAINTS
If you believe your privacy
rights have been violated, you may file a complaint with our
office or with the Secretary of the Department of Health and
Human Services. To file a complaint with our office, contact
Western’s Privacy Officer. You will not be penalized for
filing a complaint.
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