Effective date of notice: (04-01-2010)
“MAKING ORLANDO SMILE”
DR. MAXINE MONCRIEFFE, DDS, PA
10843 DYLAN LOREN CIRCLE
ORLANDO, FL. 32825
THIS NOTICE EXPLAINS HOW MEDICAL INFORMATION RELATED TO YOU CAN BE USED AND REVEALED AND HOW YOU WILL BE ABLE TO ACCESS THE SAME. KINDLY REVIEW THE INFORMATION IN THIS NOTICE CAREFULLY.
It is our legal obligation to keep your health information private, and we fully respect it. The law requires us to make you aware of our privacy practices. Our Notice clearly explains how we are obliged to protect information about your health and what your rights are regarding the same.
TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
As already stated, we use and reveal your health information, primarily for payment, treatment, and health care operations.
Following are some examples of when we reveal your information for payment purposes:
- Inquiring you about your plans regarding dental or health care plans or some mode of payment
- Preparing and sending bills or claims
- Recovering unpaid amounts – we may do this ourselves or use the services of an attorney or a collection agency.
Following are some examples of when we reveal your information for treatment purposes:
- Fixing an appointment
- Screening your teeth
- Prescribing medication and faxing the same to be filled up
- Recommending you to contact another medical practitioner or health care center for further medical treatment
- Requesting for copies of any earlier medical test undergone by you somewhere else
Managerial and administrative functions that are necessary for us to run our office fall under the category of Health Care Operations. These include:
- Internal quality assurance
- Financial or billing audit
- Management decisions
- Involvement in managed care plans
- Defense or legal issues
- Business planning
- External storage of our records
We make use of your health information in our office to serve these purposes without seeking your permission. Even if we have to reveal information about your health outside our office in this regard, we can do so without asking for your special written permission.
OTHER REASONS FOR MAKING USE OF YOUR INFORMATION AND DISCLOSING WITHOUT PERMISSION
Duringsome extreme situations, we are permitted by the law to use or reveal your health information without seeking your permission. However, it will be wrong to say that all these situations apply to us, as we may even never actually face them. Under the following situations, the law, be it state or federal, will mandate the same:
- for a specific purpose;
- for public health purposes, such reporting, investigation, or surveillance of a contagious disease and when notices are issued by the US Food and Drug Administration about drugs or medical equipment;
- for disclosing information regarding the victims of alleged domestic violence, abuse, or neglect to government authorities;
- for activities related to health oversight, such as licensing of doctors; Medicare or Medicaid audits; or for investigation into the possible health care laws violations;
- for administrative as well as judicial proceedings, such as filing reply to subpoenas or court directives or orders of any other administrative agencies;
- for the purpose of law enforcement. For example, we may release someone’s information, who is either a victim or suspected of a crime, or to inform about a crime that takes place at our premises or some other place;
- for the identification of a body or holding of an inquiry into the death by a medical examiner to ascertain the reason for death; or asking for funeral directors’ help in burial ceremony; or to the organizations handling donations of organs or tissues;
- for research related to health;
- for preventing a grave danger to either health or well being;
- for specific government functions, primarily protection of the president or high-level government officials;
- for legitimate national intelligence activities;
- for military purposes;
- for the examination into the foreign service officials’ health;
- for de-identified information;
- for worker’s compensation programs;
- for releasing a “limited data set” for research, health care operations, or public health
- for incidental disclosures that, being the byproduct of uses or disclosures that are permitted, cannot be avoided;
- for the use of business heath associates, who perform health care functions for us and commit to keeping our information regarding health confidential;
Unless you raise an objection, we will divulge relevant information about your treatment to your family or friends, who are assisting you with dental care!
We may send a reminder to you in the form of a call you or in writing so that you are aware of the scheduled appointments, or we may request to fix an appointment for routine checkup. We may also contact you to apprise you of various other services or treatments provide by us that might prove beneficial to you. If you agree with us, we will remind you about your appointment by:
- Sending you a post card
- Leaving a message on the answering machine in your home
- Leaving a message with the person who answers your calls in your absence
OTHER USES AND DISCLOSURES
We assure you that we will not use or reveal information about your health for any other purpose unless you give it to us in writing in the form of an “authorization form.” The authority to determine the “authorization form’s” content lies with the federal law.
In some cases, we may take the initiative to request you to sign the authorization form if we intend using or disclosing your information; on the contrary, in many other cases, you may start the process if you want the details from us to be sent to someone else. Normally, in this situation, you need to give us an authorization form, or use one belonging to us.
If we start the procedure and request for your approval, it will be your sole decision to either allow us or forbid us from disclosing your information. If you reject our request, we cannot make use of your information. However, on the contrary, if you agree to sign, you may revoke the same on your discretion unless we have acted in reliance on it. Make it certain that the revocation is in writing. Send them to the contact person of the office whose name, address, fax, and e-mail have been mentioned at the beginning of this Notice.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
The law provides for you many rights about your health information. You have every right to:
- ask us to confine your information for the purpose of payment, treatment (except in times of emergency), or health care operations. We need not agree to this; however, if we do agree, we must honor your request for restrictions. Send a written request, asking for restriction, to the contact person of the office at the address, fax, and e-mail mentioned at the beginning of the Notice.
- ask us to hold confidential communication with you, such as by calling you at your workplace rather than at home, by posting your information to a separate address, or by e-mailing you. We will adhere to your requests if they are acceptable to us and if you are ready to pay for any additional cost. If you want that the communication should be confidential, send a written request to the contact person of the office at the address, fax, and e-mail mentioned at the beginning of the Notice.
- ask us if you want to acquire copies of your health Information. Under the law, there are a few situations wherein we can refuse to allow access of your copies. Primarily, you will be able to acquire a copy of the information about your health within 30 days of your filing of the request (or in case the information has been kept offsite, the time can be extended to 60 days). You may have to make payment for the photocopies in advance. If we reject your request, we will follow up by sending a written explanation and issue instructions if you want a neutral opinion on our denial under the law. The law provides for 30-day time extension for us to give you the copies if we inform you in writing about the same. If you want the photocopies of your health information, kindly send a request in writing to the contact person of the office at the address, fax, and e-mail mentioned at the beginning of the Notice.
- ask us to modify your health information if it is wrong or incomplete in your view. If we agree, we will send the same within 60 days of your request. We will send the amended information to those persons who we think had the wrong information and to those who you mention. If we do not agree, you can comment about your position and include your disapproval along with your health information. Once the statements of your position and that of our denial are included in the information about your health, we will attach it along with the other documents about the permitted disclosure of information about you. The law provides for a 30-day extension only once to consider an amendment request if we notify you in writing about the extension. If you want us to amend information about your health, you need to send a request in writing, including the reasons why you want the amendment, to the contact person of the office at the address, fax, and e-mail mentioned at the beginning of the Notice.
- ask us to disclose details of your health information, collected by us within the last six years (or a lesser period). According to the law, the list should not comprise disclosures of the purpose of payment, treatment, or health care operations; incidental disclosure; disclosure required by the law; disclosure with your authority;and some other limited disclosures. We provide one such list for you free of cost every year. In case you want frequent lists, make an advance payment. We will usually reply your request within 60 days, but the law provides for only 30-day extension if we give you a written notification of the same. If you want a list, write to the contact person of the office at the address, fax, and e-mail mentioned at the beginning of the Notice.
You can even demand additional copies of this Notice of Privacy Practice even if you have already secured one by e-mail or in print form. If you want us to send additional printed copies, write to the contact person of the office at the address, fax, and e-mail mentioned at the beginning of the Notice.
OUR PRIVACY PRACTICES’ NOTICE
The law mandates us to abide by the terms and conditions laid down by this Notice of Privacy Practices so long as we do not changing it. According to the law, we have the sole discretion to change this notice any time we want. In case we alter this Notice, our new privacy practices will start applying to your health information, which is with us already, as well as to the information we may produce in the future. If we modify our Privacy Practices’ Notice, the new notice will replace the old one in our office. We will also make copies of the same available in our office and post it on our website.
If you think we have not properly honored the privacy of information about your health, you can complain about the same to us or to the US Department of Health and Human Services, Office of Civil Rights. In such a case, we will not react against you. If you want to make a complaintwith us, write to the contact person in the office at the address, fax, or e-mail mentioned at the beginning of this Notice.
If you desire, you can also talk about your grievances in person or call us.