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.
We are required by applicable federal and state law to maintain the privacy of your protected health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect September 2012 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 dental and health information that we maintain, including dental and 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 provide the new Notice at our practice location, and we will distribute it 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.
HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION
We may use and disclose dental and health information for different purposes including treatment, payment and healthcare operations. Some information such as HIV, genetic, alcohol/substance abuse and mental health records may be entitled to special confidentiality protection under applicable state and/or federal law. We will abide by these special protections s they pertain to your records. We may use and disclose health information about you without authorization for the following purposes:
Treatment: We may use or disclose your dental or health information for your treatment. For example, we may disclose your health information to a physician or other healthcare provider providing treatment to you.
Payment: We may use and disclose your dental and health information to obtain payment to you for the services we provide to you. For example, we may send claims to your dental health plan containing certain dental and health information.
Healthcare Operations: We may use and disclose your health information in connection with our periodontal operations which may include quality assessment, improvement, and licensing activities.
Persons Involved In Care: We may use or disclose dental and health information to a family member, your personal representative, or another person identified by you when they are involved in your care or in the payment of your care, of your location, your general condition, or death. This person has the authority by law to make health care decisions for you. We will treat your representative the same way we would treat you with similar respect to health information and allowing a person to pick up periodontal records, radiographs, or other similar forms of dental and health information.
Disaster Relief: We may use your dental and health information to assist in disaster relief efforts.
Marketing Health-Related Services: We will not use your dental and health information for marketing communications.
Required by Law: We may use or disclose your dental and health information when we are required to do so by law in response to a subpoena or court order.
Public Health: We may use or disclose your health information to prevent or control disease, injury, or disability: notify the appropriate government authority if we believe you have been a victim of abuse, neglect, or domestic violence; and to report reactions to medications or problems with products and recall replacement products.
Health Oversight Activities: We may disclose your personal health information to an oversight agency for activities including audits, investigations, inspections, and credentialing as necessary for licensure and for the government to monitor the healthcare system, programs, and civil rights.
Judicial and Administrative Hearings: If you are involved in a lawsuit or dispute, we may disclose your personal health information in response to a court or administrative order or in response to subpoena, discovery request or other lawful process instituted by someone else involved a dispute but only if efforts have been made to contact you about the request or to obtain an order protecting the information requested.
Workers Compensation: We may disclose your personal health information to the extent authorized by and to the extent necessary to comply with workers’ compensation or similar programs.
National Security: We may disclose to military authorities the dental and health information of Armed Forces personnel under certain circumstances. We may disclose to authorize federal officials dental and health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to the correctional institution or law enforcement official having lawful custody the protected health information of an inmate or patient under certain circumstances.
Coroners and Medical Examiners: We may release your personal health information to a coroner or medical examiner if necessary to identify a deceased person or determine the cause of death.
Secretary of Health and Human Services: We will disclose your health information to the Secretary of the US Department of Health and Human Service when required to investigate or determine compliance with HIPAA.
Appointment Reminders: We may use or disclose your dental and health information to provide you with appointment reminders (such as voicemail, email, text messages, postcards, or letters).
Your Authorization: In addition to our use of your dental and health information for the following purposes, you may give us written authorization to use your dental and health information 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 disclose your health information for any reason except those described in this notice.
YOUR HEALTH INFORMATION RIGHTS
Access: You have the right to look at or get copies of your dental health information, with limited exceptions. 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. You may also request access by sending us a letter to the address at the end of this Notice. We will charge you a reasonable cost-based fee for the cost of supplies and labor of copying. If you request copies, we will charge you $1.00 for each page after ten pages for staff time to copy your dental and health information, and postage if you want the copies mailed to you. If you request an alternative format (flash drive, etc.), 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 dental and health information for a fee as outlined above. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure. If you are denied a request for access, you have the right to have the denial reviewed in accordance with the requirements of applicable law.
Disclosure Accounting: With the exception of certain disclosures, you have the right to receive an accounting of disclosures of your protected health information in accordance with present laws and regulations. You must request this in writing to the Privacy Official. 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 restrictions on our use or disclosure of your protected dental and health information. You must make your request in writing to the Privacy Official. Your request must include what information you want limited and whether you want to limit our use or disclosure and who you want the limits to apply to. We are not required to agree to your request unless it involves a dental or health plan for purposes of carrying our payment or healthcare operations and the information pertains solely to a dental or health care item or service which you or a person on your behalf has paid our practice in full.
Alternative Communication: You have the right to request that we communicate with you about your dental and health information by alternative means or at alternative locations. You must make your request in writing and must specify means and location. We will accommodate all reasonable requests. If we are not able to contact you using the alternative request, we may contact you using the information we have on file.
Amendment: You have the right to request that we amend your dental or 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. If we agree to your request, we will amend your health records and notify you of the change. If we deny your request, we will notify you with a written explanation of why it was denied.
Right to Notification of a Breach: You will receive notification of a breach of your unsecured protected health information as required by law.
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 dental and health information or in response to a request you made to amend or restrict the use or disclosure of your dental and 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.
NORTH IOWA PERIODONTICS, PLLC
1010 4TH ST. SW, STE 300
MASON CITY, IOWA 50401
HIPAA Privacy Officer: Marilyn Kiser, Practice Administrator
Telephone: 641-424-0301 Fax: 641-424-0302
HIPAA Security Officer: DeAnne Maroo, Office Manager
Telephone: 641-424-0301 Fax: 641-424-0302