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 September 1, 2013, and will remain in effect until we amend
or 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 Services of Arizona,
Inc., P.O. Box 14227, Orange, CA 92863, Phone: (800) 417-4444. E-mail:
Organizations covered by Joint Notice:
Western Dental Services of Arizona, Inc.
Premier Choice Dental, Inc.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
For Treatment We may use and disclose your health information
to provide you with medical treatment or services. We may also disclose your health
information to other providers involved in your care.
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.
For Payment We may use and disclose health information about
you to obtain payment for health care services we or others provide to you. 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 and Refill Reminders; Prescription Information We
may contact you by phone, mail, email, or other modes of communication as a reminder
that you have an appointment for treatment or medical care at the office. We may
also provide you with refill reminders or communicate with you about a drug or biologic
that is currently prescribed to you so long as any payment we receive for making
the communication is reasonably related to our cost of making the communication.
Treatment Alternatives We may contact you by phone, mail,
email, or other modes of communication to inform you about or recommend possible
treatment options or alternatives that may be of interest to you.
Health-Related Products and Services We may contact you by
phone, mail, email, or other modes of communication to inform you about health-related
products or services that may be of interest to you.
Surveys We may contact you by phone, mail, email or other
modes of communication to ask you to participate in patient satisfaction surveys,
or to provide you with other quality assessment and improvement communications.
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 or lessen a serious
threat to your health and safety or the health and safety of the public or another
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;
- To assist law enforcement officials in their law enforcement duties.
Research We may use and disclose health information about
you for research projects if we receive special approval from a privacy board or
institutional review board. Under certain circumstances, your health information
may also be disclosed without your permission to researchers preparing to conduct
a research project, for research on decedents or as part of a data set that omits
your name and other information that can directly identify you.
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 We
may use and disclose your health information to units of the government with special
functions, such as the U.S. military or the U.S. Department of State under certain
circumstances specified by law.
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
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, nonaccidental
physical injuries, reactions to medications or problems with products.
Health Oversight Activities We may disclose health information
to a health oversight agency. These disclosures may be necessary for certain state
and federal agencies to monitor the health care system, government programs, and
compliance with applicable 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 or other lawful
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
Marketing Except for marketing information given in a face-to-face
encounter or promotional gifts of nominal value, we must obtain your written authorization
prior to using your health information for purposes that are considered marketing
under the federal health information privacy law commonly known as HIPAA. For example,
we will not accept any payments from other organizations or individuals in exchange
for making communications to you about treatment, therapies, health care providers,
settings of care, case management, care coordination, products or services unless
you have given us your authorization to do so or the communication is permitted
Sale of Health Information We will not disclose your health
information that is considered a sale of health information under HIPAA without
your written authorization.
Sensitive Health Information There are special privacy protections
under federal and state laws for certain sensitive health information, such as alcohol
and drug abuse treatment information, HIV information, and mental health information
(such as psychotherapy notes). We will not disclose your sensitive health information
without your written authorization unless permitted or required by law. In addition,
the Western Dental Plan will not use your genetic information for underwriting purposes.
Your Written Authorization 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.
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:
We did not create, unless the person or entity that created the information is no
longer available to make the amendment.
Is not part of the health information that we keep.
You would not be permitted to inspect and copy.
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 While we will
consider all requests for additional restrictions carefully, we are not required
to agree to a requested restriction unless the requested restriction is to a health
plan for payment or health care operations purposes and the information you would
like to restrict to the health plan pertains solely to a health care item or service
you paid out of pocket. 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.
Right to be Notified of Breach You have the right to be notified
by us if we discover a breach of your unsecured protected health information.
Right to a Paper Copy of This Notice. You have the right to
a paper copy of this Notice. You may ask us to give you a copy of this Notice at
any time. Even if you have agreed to receive this Notice electronically, you are
still entitled to a paper copy of this Notice.
Copies of this Notice are available at Western’s offices, or you may obtain
a copy at our website at www.westerndental.com.
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.
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.