PRIVACY POLICY FOR
DR. ASDELL
Notice of Privacy
Practices for Protected Health Information
Effective Date: April 14, 2003
This
notice describes how medical information about you may be used and disclosed
and how you can get access to this information.
Please review it carefully!
With your consent, the practice
is permitted by federal privacy laws to make uses and disclosures of your
health information for purposes of treatment, payment, and health care
operations. Protected health information
is the information we create and obtain in providing our services to you. Such information may include documenting your
symptoms, examination and test results, diagnoses, treatment, and applying for
future care or treatment. It also
includes billing documents for those services.
Example of uses of your health information for treatment purposes:
A nurse obtains treatment
information about you and records it in a health record. During the course of your treatment, the
doctor determines a need to consult with another specialist in the area. The doctor will share the information with
such specialist and obtain input.
Example of use of your health information for payment purposes:
We submit a request for payment
to your health insurance company. The
health insurance company requests information from us regarding medical care
given. We will provide information to
them about you and the care given.
Example of Use of Your Information for Health Care Operations:
We obtain services from our
insurers or other business associates such as quality assessment, quality
improvement, outcome evaluation, protocol and clinical guidelines development,
training programs, credentialing, medical review, legal services, and
insurance. We will share information about you with such insurers or other
business associates as necessary to obtain these services.
Your Health Information Rights
The health record we maintain and
billing records are the physical property of the practice. The information in it, however, belongs to
you. You have a right to:
-
Request a restriction on certain uses and
disclosures of your health information by delivering the request in writing to
our office. We are not required to grant
the request but we will comply with any request granted;
-
Request that you be allowed to inspect and copy
your health record and billing record—you may exercise this right by delivering
the request in writing to our office;
-
Appeal a denial of access to your protected
health information except in certain circumstances;
-
Request that your health care record be amended
to correct incomplete or incorrect information by delivering a written request
to our office;
-
File a statement of disagreement if your
amendment is denied, and require that the request for amendment and any denial
be attached in all future disclosures of your protected health information;
-
Obtain an accounting of disclosures of your
health information as required to be maintained by law by delivering a written
request to our office. An accounting
will not include internal uses of information for treatment, payment, or
operations, disclosures made to you or made at your request, or disclosures
made to family members or friends in the course of providing care;
-
Request that communication of your health
information be made by alternative means or at an alternative location by
delivering the request in writing to our office; and,
-
Revoke authorizations that you made previously
to use or disclose information except to the extent information or action has
already been taken by delivering a written revocation to our office.
If you want to exercise any of
the above rights, please contact B.J. Asdell, D.D.S. at (574) 289-0080 or
707 N. Michigan St. Suite 300 South
Bend, IN
46601,
in person or in writing, during normal hours.
He will provide you with
assistance on the steps to take to exercise your rights.
Our Responsibilities
The practice is required to:
-
Maintain the privacy of your health information as
required by law;
-
Provide you with a notice of our duties and
privacy practices as to the information we collect and maintain about you;
-
Abide by the terms of this Notice;
-
Notify you if we cannot accommodate a requested
restriction or request; and
-
Accommodate your reasonable requests regarding
methods to communicate health information with you.
We reserve the right to amend,
change, or eliminate provisions in our privacy practices and access practices
and to enact new provisions regarding the protected health information we
maintain. If our information practices
change, we will amend our Notice. You
are entitled to receive a revised copy of the Notice by calling and requesting
a copy of our "Notice" or by visiting our office and picking up a
copy.
To Request Information or File a
Complaint
If you have questions, would like
additional information, or want to report a problem regarding the handling of
your information, you may contact
B.J. Asdell,
D.D.S. at (574) 289-0080.
Additionally, if you believe your
privacy rights have been violated, you may file a written complaint at our
office by delivering the written complaint to B.J. Asdell, D.D.S. You may also file a complaint by mailing it
or e-mailing it to the Secretary of Health and Human Services.
-
We cannot, and will not, require you to waive
the right to file a complaint with the Secretary of Health and Human Services
(HHS) as a condition of receiving treatment from the practice.
-
We cannot, and will not, retaliate against you
for filing a complaint with the Secretary.
Other Disclosures and Uses
Notification
Unless you object, we may use or disclose your
protected health information to notify, or assist in notifying, a family
member, personal representative, or other person responsible for your care,
about your location, and about your general condition, or your death.
Communication
with Family
Using our best judgment, we may disclose to a family
member, other relative, close personal friend, or any other person you
identify, health information relevant to that person's involvement in your care
or in payment for such care if you do not object or in an emergency.
Food and Drug Administration (FDA)
We may disclose to the FDA your protected health
information relating to adverse events with respect to products and product
defects, or post-marketing surveillance information to enable product recalls,
repairs, or replacements.
Workers
Compensation
If you are seeking compensation through Workers
Compensation, we may disclose your protected health information to the extent
necessary to comply with laws relating to Workers Compensation.
Public Health
As required by law, we may disclose your protected
health information to public health or legal authorities charged with
preventing or controlling disease, injury, or disability.
Abuse & Neglect
We may disclose your protected health information to
public authorities as allowed by law to report abuse or neglect.
Correctional
Institutions
If you are an inmate of a correctional institution,
we may disclose to the institution, or its agents, your protected health
information necessary for your health and the health and safety of other
individuals.
Law
Enforcement
We may disclose your protected health information
for law enforcement purposes as required by law, such as when required by a
court order, or in cases involving felony prosecutions, or to the extent an
individual is in the custody of law enforcement.
Health
Oversight
Federal law allows us to release your protected
health information to appropriate health oversight agencies or for health
oversight activities.
Judicial/Administrative
Proceedings
We may disclose your protected health information in
the course of any judicial or administrative proceeding as allowed or required
by law, with your consent, or as directed by a proper court order.
Other Uses
Other uses and disclosures besides those identified
in this Notice will be made only as otherwise authorized by law or with your
written authorization and you may revoke the authorization as previously
provided.
Website
If we maintain a website that provides information
about our entity, this Notice will be on the website.
Effective Date: April 14, 2003
I, ________________________, hereby acknowledge that I have
received a copy of this practice’s Notice of Privacy Practices. I have been given the opportunity to ask any
questions I may have regarding this Notice.
_______________________________________ ________________________________
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