NOTICE OF PRIVACY PRACTICES

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. OUR LEGAL DUTY We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give this Notice about our privacy practices, and 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 took effect 04/14/03, 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 health information that we maintain, including 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 make the new Notice available 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 contact information listed in this Notice. USES AND DISCLOSURES OF HEALTH INFORMATION We may use and disclose health information about you [appropriately] in these situations that may arise during the normal daily activities of this dental office: Scheduling Appointments and ContactingYou to Remind You of Those Appointments: We may use and disclose your health information to schedule an appropriate dental or hygiene appointment for you into the computer’s electronic schedule, which is kept confidential. Our Front Office may try to remind you about your appointment(s) by phone-call, post-cards and/or other means of contact..If you have a dental appointment and desire a “first opening or first cancellation” re-scheduling,you will also be contacted as these openings arise. Treatment: We may use or disclose your health information to another dentist, a physician, or other healthcare provider involved in providing treatment to you. Payment: We may use and disclose your health information to obtain payment for services we provide to you. Examples of this would include,but not be limited to: billing for your outstanding account balance; submitting claim forms and/or supporting information and/or radiographic images and/or test results and/or clinical observations to an Authorized Third Party such as a dental insurance company, an insurance company, and/or a Worker’s Compensation program.; employing collection methods and/or collection services to obtain payment on your delinquent account balance. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, conducting training programs,accreditation, certification, licensing, or credentialing activities. We may use and disclose health information about you [appropriately] in these situations that may arise during the normal daily activities of this dental office: Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or 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 use or disclose your health information for any reason except those described in this Notice. To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so. Persons Involved In Care: We may use or disclose health information to notify, or to assist in the notification of (including identifying or locating) a family member, your personal representative, or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to of disclosures of your health inform- ation, we will provide you an opportunity to object to such uses or disclosure. In the event of your incapacity or emergency circumstances we will disclose health information based on determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical/dental supplies, radiographic images, or other similar forms of health information. We may use and disclose health information about you [appropriately] in these situations that may arise during the normal daily activities of this dental office: Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization. Required By Law: We may use or disclose your health information when we are required to do so by law. Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counter-intelligence, and other national security activities. We may disclose to correctional institutions or law enforcement officials having lawful custody the protected health information of inmates or patients under certain circumstances. Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders.Examples would include but not be limited to: phone-calls, post-cards, letters, voice-mail messages, e-mails, etc. PATIENT RIGHTS Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (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 in this Notice. You may also request access by sending us a letter to the office’s address listed in this Notice.) You must give us reasonable advance notice (e.g. 24 hrs to 7 days) to gain access to your health information and allow for reasonable required staff time to prepare and duplicate any dental records being transferred or picked-up from this dental office. We must keep the original dental records but will provide adequate duplicates. Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, healthcare operations, and certain other activities, for the last 6 years, but not before April 14, 2003. 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. Restrictions: You have the right to request that we place additional restrictions on our use of disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means, or to alternative locations. You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request. Amendment: You have the right to request that we amend your 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. Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form. 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 have violated your privacy rights; or you disagree with a decision we made about access to your health information; or in response to a request you made to amend or restrict the use of disclosure of your health information; or to have us communicate with you by alternative means or locations; you may complain to us using the contact information listed at the end of this Notice.You may also submit a written complaint to the U.S. Dept. of Health and Human Services. We will provide you with the address to file your complaint with the Office for Civil Rights. 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 us or with the U.S. Dept. of Health and Human Services. Contact Officer: Gregg K. Mullens, Pharm.D., D.D.S. Owner / Dentist 413-773-7766 Fax: 413-773-3050 40 School Street, Suite 6, Greenfield, MA 01301-2436 email: info@greenfielddentist.com website:http://www.greenfielddentist.com CLICK HERE FOR A PRINTABLE PDF OF THIS PRIVACY NOTICE Questions about our offices notice of privacy Practices, click here