Crow Family Dental

Notice of Privacy Practices

The information provided below illustrates the manner your protected health information could be used and disclosed and how you can get access to this information. This important document should be reviewed thoroughly. Managing the privacy of your protected health information is extremely important to Crow Family Dental.

Crow Family Dental Legal Responsibilities: As mandated by Federal and State legal requirements your protected health information must be protected.  As part of these regulations we are required to ensure you are aware of privacy policies, legal duties and your rights to your protected health information. This notice of privacy policies, outlined below, will be in effect for the duration and must be followed by our practice.  This notice will be in effect until it is replaced and becomes effective _04_/_07_/_2014_.

We reserve the right to modify our privacy policies and the terms of this notice at any time, and will make such modifications within the guidelines of the law.  We reserve the right to make the modifications effective for all protected health information that we maintain, including protected health information we created or received before the changes were made. Changing this notice will precede all significant modifications.  This notice will be 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 information listed at the end of this Notice.

PROTECTED HEALTH INFORMATION USE AND DISCLOSURE

Information regarding your health may be used and disclosed for the purpose of treatment, payment, and other healthcare operations.  Examples cited below further explain the use and disclosure process.

Treatment: Use and disclosure of your protected health information may be provided to a physician or other healthcare provider providing treatment to you.

Payment: Your protected health information may be used and disclosed to obtain payment for services we provide to you, including billing, collections, claims management, and determinations of eligibility and coverage to obtain payment.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations, including quality assessment and improvement activities, conducting training programs, licensing and credentialing activities.

Your Authorization:  At any time you may provide in writing your authorization for use and disclosure of your protected health information for any purpose.  You may choose to revoke your written permission at any time.  The revocation must be in writing.  If you revoke your written authorization, it will not affect any use or disclosure prior to the revocation.

Your protected health care information may be used and disclosed to you, as described in the patient rights section of this notice.  In addition, your protected health information may be used and disclosed to a family member, friend, or other person to the extent necessary to assist you with your healthcare, but only with your authorization.

Individuals Involved in Your Care or Payment for Your Care:  In order to accommodate the notification of your location, your general condition, or death, your health information may be used or disclosed to a family member, your personal representative, or another person responsible for your care.  If you are present and wish to object to such disclosures of your health information, you may do so.  To the extent you are incapacitate or emergency circumstances exist, we will disclose health information using our professional judgment  disclosing only health information that is directly relevant to the person’s involvement in your healthcare.  We will use our professional judgment and our experience with common practices to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of protected health information.

Disaster Relief:  We may use or disclose your health information to assist in disaster relief efforts.

Required by Law:  We may use or disclose your health information when we are required to do so by law, or in response to a subpoena or court order.

Public Health Activities:  We may disclose your health information for public health activities, including disclosures to:

Research:  We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information.

Coroners, Medical Examiners, and Funeral Directors:  We may release your PHI to a coroner or medical examiner.  This may be necessary, for example, to identify a deceased person or determine the cause of death.  We may also disclose PHI to funeral directors consistent with applicable law to enable them to carry out their duties. 

Appointment Reminders:  Your PHI may be used to assist you with appointment reminders in the form of voicemail messages, postcards, or letters.

Marketing Health-Related Services:  The use of your protected health information for the purpose of marketing communications is prohibited without your written authorization.  The sale of your PHI is also prohibited without your express written authorization. You may revoke an authorization in writing at any time.  Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization.

PATIENT RIGHTS

Access:  You have the right to look at or get copies of your health information, with limited exceptions.  You must make the request in writing.  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.  If you request information that we maintain on paper, we may provide photocopies.  If you request information that we maintain electronically, you may request an electronic copy.  If we are able to do so, we will accommodate your request.  We will charge you a reasonable cost-based fee for the cost of supplies and labor of copying, and for postage if you want copies mailed to you.  Contact us using the information listed at the end of this Notice for an 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:  You have the right to receive an accounting of disclosures of your health information in accordance with applicable laws and regulations.  To request an accounting of disclosures of your health information, you must submit your request 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 the additional requests.

Right to Request a Restriction:  You have the right to request additional restrictions on our use or disclosure of your PHI by submitting a written request to the Privacy Official.  Your written request must include (1) what information you want to limit, (2) whether you want to limit our use, disclosure or both, and (3) to whom you want the limits to apply.  We are not required to agree to your request except in the case where the disclosure is to a health plan for purposes of carrying out payment or health care operations, and the information pertains solely to a health care item or service for which you, or a person on your behalf (other than the health plan), has paid our practice in full.

Alternative Communication:  You have the right to request that we communicate with you about your health information by alternative means or at alternative locations.  You must make your request in writing.  Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request.  We will accommodate all reasonable requests.  However, if we are unable to contact you using the ways or locations you have requested, we may contact you using the information we have.

Amendment:  You have the right to request that we ament 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.  If we agree to your request, we will amend your record(s) and notify you of such.  If we deny your request for an amendment, we will provide you with a written explanation of why we denied it and explain your rights.

Right to Notification of a Breach:  You will receive notifications of breaches of your unsecured protected health information as required by law. 

Electronic Notice:  If you receive this notice electronically, you are entitled to receive this notice in writing as well.

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 if you disagree with a decision we made about access to your health information or in response to a request you made to ament or restrict the use or disclosure of your 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.

Privacy of your protected health information remains extremely important to us.  We are committed to ensure your privacy.  If you file a concern with the U.S. Department of Health and Human Resources, we will not retaliate in any way.  We are available to assist you with any questions, concerns, or complaints.

Our Privacy Official:  Nancy Schmidt

Telephone:   (715) 344-6390

Address:  15 Park Ridge Drive, Stevens Point, WI  54481

Email:  crowfamilydental@live.com