NOTICE OF PRIVACY PRACTICES FOR NEW AGE DENTISTRY OF NAPLES: This notice describes how health information about you may be used and disclosed and how you can gain access to this information. Please review the information carefully. The privacy of your health information is important to our office.
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 you this Notice about our privacy practices, 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 takes affect March 1, 2004, and will remain in effect until we replace the Notice.
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 Noticed 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 the Notice, please contact us using the information listed at the end of this Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:
Treatment: We may use or disclose your health information to a physician or other healthcare professional providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include but are not limited to quality assessment, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation and certification, and licensing or credentialing activities.
Your Authorization: In addition to our use of your health information for treatment, payment, or health 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 anytime. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. We cannot use or disclose your health information for any reason except for those described in this Notice.
To Your Family Friends: We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your healthcare, but only with your permission.
Persons Involved in Care: We may use or disclose health information to notify, or 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 the use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a 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 supplies, x-rays, or other similar forms of health information.
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 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 of protected health information of an inmate or a patient under certain circumstances.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders including but not limited to voicemail messages, postcards, or letters
Access: You have the right to look at or obtain copies of your health information, with limited exceptions. You may request that we provide you with copies in a format other than photocopies. We will use the format you request unless we cannot practically do so. You must make a request in writing to obtain access to your health information. The request can either be in letter format mailed to the address listed at the end of this Notice or you may obtain a request form directly from our office. We will charge you a reasonable cost-based fee for such expenses as copies, postage, alternate format expenses, and staff time.
Disclosure Accounting: You have the right to receive a list of instance 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 six (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 requests.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, will not abide by our agreement (except in emergency).
Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or alternate locations. You must make this 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.
Amendment: You have the right to request that we amend your health information. Your request must be made 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 also have the right to receive this Notice in written form.
QUESTIONS AND COMPLAINTS
If you would like to obtain additional information about our privacy practices or if you have questions or concerns, please contact us.
If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about your health information, or in response to a request you made to amend 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 may also 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.
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 with us or with the U. S. Department of Health and Human Services.
Contact Officer: Denis Vassilinin
Telephone/Fax: (239) 348-8370/(239) 529-5673
E-Mail: [email protected]
Address: 7550 Mission Hills Dr Unit 122 Naples, FL, 34119