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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 READ IT CAREFULLY


We provide this notice to comply with the Privacy Regulations issued by the Department of Health and Human Services in accordance with the Health Insurance Portability an Accountability Act of 1996 (HIPAA)

This NOTICE OF PRIVACY PRACTICES describes the privacy policies and procedures we adhere to and extends to all healthcare providers and dental office employees for:

Peter A. Russo, 18800 Main Street #201, Huntington Beach, CA 92648. Phone: (714) 842-2515

ABOUT YOUR
PROTECTED HEALTH INFORMATION (PHI):
  • PHI includes any individually identifiable health information transmitted or maintained by our office in any form or medium (electronically, on paper or orally).
  • PHI is protected by law and provides penalties for healthcare providers that misuse or disclose it to unauthorized persons.
  • Employment records maintained by a covered entity in its capacity as an employer from the definition of PHI.
  • The protection of your PHI is something our dental office take very seriously.
ABOUT YOUR
NOTICE OF PRIVACY PRACTICES: (NOTICE)
We are required by law to:
  • Give you a copy of this NOTICE when you sign a Patient Consent Form
  • Post the NOTICE in a prominent place and on our Website.
  • Make the NOTICE available to patients upon request.
  • Provide you with a "revised" NOTICE, if we make material changes to our NOTICE and will do so at your next office visit. after the changes to the NOTICE have been made.
  • Follow the policies and conditions of the NOTICE that is currently in effect.
We reserve the right to:
  • Change our NOTICE at any time
  • Make revisions and changes to our NOTICE effective for PHI already in our system as well as PHI we obtain from our patients in subsequent visits.
ABOUT USES
AND DISCLOSURES OF YOUR PHI:
We may use and disclose your PHI
  • For TREATMENT: Means providing, coordinating, or managing healthcare and related services by one or more healthcare providers. For example, we may use PHI we receive from your previous dentist to help determine a treatment plan for your current care.
  • For PAYMENT: Means such activities as obtaining reimbursement for dental services, billing or collection activities, confirming insurance coverage. For example, we may use and disclose your PHI to obtain payment for dental services.
  • For HEALTHCARE OPERATIONS: : Include the business aspects of running our practice, such as conducting quality assessment and improvement activities, employee training, auditing functions, cost-management analysis, and customer service. For example, we might hire a dental consultant to review our scheduling procedures. We may disclose PHI for treatment and payment activities of another covered entity or a health care provider for certain health care operations of another covered entity.
  • When REQUIRED BY FEDERAL, STATE, OR LOCAL LAW: When required by the U.S. Department of Health and Human Services as part of an investigation or determination of the facilities compliance with relevant laws.
  • TO YOUR FAMILY & FRIENDS: IF you agree, we may disclose your PHI to a family member, friend or another person to the extent necessary to help with your healthcare or with payment for your healthcare. For example, if another person was paying for your dental treatment, you might ask us to explain the treatment to that person.
  • PERSONS INVOLVED IN YOUR CASE: Unless you object, we may disclose to a member of the family, a close friend, or any other person you identify, your PHI as it relates to the person's invlovement in your healthcare. If you are unable to agree or object to disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on professional judgement. We may use or disclose your PHI to assist in notifying a fmaily member, personal representative, or any other person that is responsible for your care of your location, general condition, or death.
  • APPOINTMENT REMINDERS AND OTHER USES: your PHI may be used to remind you by phone, computer, or mail of a dental appointment. For example, we may leave you a message containing PHI on you answering machine. Or we may include PHI on recall cards sent to your home or mail you information regarding alternative dental treatment options or dental related services. We will send you recall notices.
  • MARKETING: We will not use or disclose your PHI for marketing communications without your written authorization.
  • EMERGENCY SITUATIONS: To assist in disaster relief efforts or during a medical emergency.
  • RESEARCH: To researchers when their research has been approved by an institutional review board that has reviewed the research proposal and protocals to ensure the privacy of your PHI
  • PUBLIC HEALTH AGENCIES: To report disease, injury, vital events, and to conduct public health surveillance, investigation and/or intervention. To a health oversight agency for oversight activities authorized by law including audits, investigations, inspections, licensure and/or accredidation or disciplinary actions, administrative and/or legal proceedings. To prevent or lessen a serious threat to the health or safety of another person or the public and as authorized by laws relating to workers' compensation or similar programs. To the coroner, medical examiner or a funeral director, to an organ donations and procurement organization if you are an organ donor.
  • LAWSUITS, DISPUTES, INVESTIGATIONS AND GOVERNMENT ACTIVITIES: We may disclose your PHI if required to do so by a court order, administrative order, subpoena or discovery request by you or another individual invloved in the dispute and in the course of certain judicial or administrative proceedings and to federal officials for intelligence and national security activities authorized by law.
  • LAW ENFORCEMENT: To law enforcement agencies or for specilized government functions. For example, for the indentification of victims of a crime, to identify or locate a suspect, material witness, missing person, or fugitive or in response to a court order, warrant, summons or subpoena.
  • MILITARY: Our practice may disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities to do so.
  • INMATES: If you are an inmate of a correctional institution and if the institution is going to provide health-care for you. Or, to protect the health and safety of the inmate or others to protect the health and safety of the institution.
  • FOOD AND DRUG ADMINISTRATION: (FDA) Covered entities may disclose PHI, without authorization, to a person subject to the jurisdiction of the FDA for public health purposes related to the quality, safety or effectiveness of FDA-regulated products or activities such as collecting or reporting adverse events, dangerous products, and defects of problems with FDA-regulated products.
  • ANY OTHER ISSUES: Will be made only with your written authorization.
ABOUT YOUR PATIENT RIGHTS:
As a patient you have the right to:
  • Obatin a copy of this Notice, even if you agreed to accept it electronically.
  • Request that we communicate with you in a particular manner or at a certain location. For example, you may request we contact you only at home by phone and not on your fax machine.
  • Confidentiality
  • Restrict how your PHI is used or disclosed and to whom we may disclose it.
    • Requests to restrict and limit PHI must be in writing:
    • We are not required to agree to your request.
    • We will abide by the written consent form you sign and by local, state and federal law.
You have the right to:
  • Request an "Accounting of Disclosure of Your PHI" for yourself or persons you have legal guardianship over.
  • Request Form avialable at front desk.
    • Requests must be in writing and include:
      • The form the disclosure is requested in. For example, photocopies or disk.
      • A time period (not more than six years back and not before April 14, 2003.)
      • How you want to be contacted once the request is fulfilled
    • We may charge a fee for requests:
      • A will be estimated and communicated to you prior to fulfiling your request.
      • You may accept or reject your request at that time
Patiente have the right to provide
Authorization for uOther Uses and Disclosures:
  • Our practice will obtain your written authorization for uses and disclosures that are not identified by this NOTICE or permitted by applicable law. For eaxmple, we may ask for authorization to use your name or other PHI in an advertisment about our practice
  • You have the right to revoke, at any time and in writing, any authorization you provide us regarding the use and disclosure of your PHI.
  • After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization.
  • Please note: We are required by law to retain records of your care.

Patients have rights to
Access, Ispect and/or Copy PHI:
  • Including medical and billing records for themselves and persons under theri custodial or legal guardianship (with proof of that legal relationship)
  • Information contained in a "designated record set", medical, billing and any other records that we use to help make decisions about your healthcare.
  • Access must be provided within five (5) working days of receipt of written request.
  • Photocopies must be provided within ten (10) working days of receipt of written request.
  • Under federal law you may not inspect or copy:
    1. Psychotherapy notes;
    2. Information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative proceeding;
    3. PHI that is subject to law that prohibits access to PHI
    4. In some circumstances, you have the right to have the decision to deny reviewed.
  • PHI may be requested in a format other than photocopies;
    1. Requests must me in writing. (Ask for a form at the front desk).
    2. Or, make a request by letter addressed to our Office Privacy Contact Person. (OCP)
    3. Peter A Russo at the address on front of this NOTICE
  • A cost-based fee may be charged for this service:
    1. $.20 per copy will be charged for photocopies;
    2. Plus $15.00 per hour for employee time to locate and duplicate data;
    3. Plus postage, if you want your health information mailed to you.
    4. Fees for this service are due at time of delivery of copies.
    5. PHI requested in a format other than photocopies will be provided on a cost-based fee and a case-by-case basis. (Cost of tape, disk, etc., plus labor) For details see OCP.
  • We may under limited circumstances, deny your request to inspect and copy.
    • You have the right to challenge our denial.
    • A patient challenge to denial will be presented to a Dentist (or committee) other than the Dentist issuing the denial, for review. After a review, a finding and decision will be made. Our office will abide by the decision of the Dentist making the review.
Patient have the right to
Request PHI be Amended:
  • If you believe your PHI is wrong or incomplete.
  • This right extends to you for the period of time our office maintains your PHI.
  • Request Forms available at the front desk.
  • Requests to Amend PHI must be in writing and include:
    1. A reason that supports why you believe the PHI is incorrect/incomplete
    2. The date
    3. Your signature
  • We may deny your Request to Amend PHI if:
    • You fail to submit the Request in writing;
    • And/or fail to include a reason to support the request;
    • If the information you asked to amend was not created by us, unless the person or entity that created the information is no longer available to make the amendment.
    • If the information you requested is not part of your PHI kept by our office, or not information which you would be permitted to inspect and copy; or the PHI information is inaccurate and incomplete.
ABOUT COMPLAINTS
Patients have the right to complain:
  • If you feel your privacy rights have been violated, you have the right to file a formal, written complaint with us at the address on the front of this NOTICE, or with the DHS, Office of Civil Rights.
  • Complaints to us will be turned over immediately to our Privacy Officer, the owner of the dental practice.
  • Complaints must be submitted in writing
  • Complaint Forms available at the front desk.
  • All complaints shall be investigated thoroughly by our Privacy Officer.
  • You may not be penalized for making a complaint.
Address Complaints To:

Peter A. Russo, DDS
Attention: Privacy Officer
At address on the front of this NOTICE		 And/or: DHS
U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Ave. S.W.
Washington, D.C. 20201
(877) 696-6775 (toll-free)


Dear Patient,
Thank you for allowing us the privilage of
providing your dental care. The security of your protected
health information is an obligation and duty every
member of our dental team takes very seriously.
you have our pledge to be worthy of your trust.

          Sincerely,
          The Dental Team