Notice of Privacy Practices II
Notice of Privacy Practices – Effective September 12, 2013
This Notice describes how your health information may be used and disclosed, and how you can access this information. Please review it carefully.
We are required to keep your health information secure and confidential, by law. Also by law, we need to give you this Notice and to follow the terms of this Notice.
The law permits us to use or disclose your health information to those involved in your treatment. For example, a review of your file by another doctor whom we may involve in your care.
We may use or disclose your health information for payment of your services. For example, we may send a report of your treatment or progress to your insurance company.
We may use or disclose your health information for our normal healthcare operations. For example, for quality assessment and improvement activities, conducting training programs, and licensing activities.
We may share your medical information with our business associates, such as a billing service.
We have a written contract with each business associate that requires them to protect your privacy.
We may use your information to contact you. For example, we may send newsletters or other information to you.
We may also call, text, or email and remind you about your appointments. If you are not home, we may leave this information on your answering machine or with the person who answers the telephone.
In an emergency, we may disclose your health information to a family member or another person responsible for your care.
We will need to release some or all of your health information, when required by law.
If this practice is sold, your information will become the property of the new owner. Your health information will not be sold in any other manner.
Except as described above, this practice will not use or disclose your health information without your prior written authorization.
You may request in writing that we not use or disclose some or all of your health information as described above. We will let you know if we can fulfill your request.
You have the right to know of any uses or disclosures we make with your health information beyond the above normal uses.
You have the right to receive communication about your health information in the manner you prefer. We will also use whatever communication method, number or system you prefer to contact you.
You have the right to transfer a copy of your health information to another practice. Notify us in writing of where you would like us to send a copy of your health information for you.
You have the right to see and receive a copy of your health information, with a few exceptions. Give us a written request regarding the information you want to see. If you want a copy of your records, we may charge you a reasonable fee for the copies. If you would like a digital copy of your records, let us know which type of file you would like and we will try to meet your needs.
You have the right to request an amendment or change to your health information, in writing. If you wish to include a statement in your file, please give it to us in writing. We may or may not make the changes you request, but will include your statement in your file. If we agree to an amendment or change, we will not remove nor alter earlier documents, but will add new information.
You have the right to receive a report of who we disclose your information to.
If our privacy and security measures or systems are breached in any way, we will notify you. You have the right to receive a copy of this Notice.
If we change any of the details of this Notice, we will post the new Notice clearly and prominently at our practice location, on our website, and we will provide copies of the new Notice upon request.
You may file a complaint with the Department of Health and Human Services in writing (200 Independence Avenue, S.W., Room 509F, Washington, DC 20201), online (http://www.hhs.gov) or by email (OCRComplaint@hhs.gov). You will not be retaliated against for filing a complaint.
Please contact our Privacy Officer at (407)286-2557 for more information, to make a request, to file a complaint with us or for assistance regarding your health information privacy.
You may refuse to sign this acknowledgment.
The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for The Loving Walk-In Dental Clinic of Orlando on this . A copy of this signed, dated Acknowledgement shall be as effective as the original.
If you are the legal representative of the patient, please print the patient’ s name(s) and describe your authority.
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Document Name: Notice of Privacy Practices II
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