Notice of Privacy Practices

This Notice of Privacy Practices describes how this facility may use and disclose your protected health information (PHI) to carry out treatment, payment or healthcare operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected Health Information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related healthcare services.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice, at any time. The new notice will be effective for all protected health information that is maintained at that time. Upon your request, this facility will provide you with any revised Notice of Privacy Practices by calling the practice and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.

1. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION BASED UPON YOUR WRITTEN CONSENT

You will be asked by this facility to sign a consent form. Once you have consented to use and disclosure of your protected health information for treatment, payment and healthcare operations by signing the consent form, this facility will use or disclose your protected health information as described in this Section. Your protected health information may be used and disclosed by this facility, the office staff and others outside of our office that are involved in your care and treatment for the purpose of providing services to you. Your protected health information may also be used and disclosed to pay your medical care bills and to support the operation of this facility’s practice.

Treatment:  We will use and disclose your protected health information to provide, coordinate or manage your dental care and any related services. This includes the coordination or management of your dental care with a third party that has already obtained your permission to have access to your protected health information. In addition, this facility may disclose your protected health information to another physician or healthcare provider who, at the request of this facility becomes involved in your care by providing assistance with your medical care diagnosis or treatment of this facility.

Payment:  Your protected health information will be used, as needed, to obtain payment for your dental care services. This may include certain activities that your dental insurance plan may undertake before it approves or pays for the dental care services this facility recommends for you.

Healthcare Operations:  We may use or disclose, as needed, your protected health information in order to support the business activities of this facility’s practice. In addition, this facility may use a sign-in device at the front desk where you will be asked to sign your name. We may also call you by name in the waiting room when the staff is ready to see you. We may use or disclose your protected health information, as needed, to contact you to remind you of your appointment.

We will share your protected health information with third party “business associates” that perform various activities for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, this facility will have a written contract that contains terms that will protect the privacy of your protected health information.

Uses and Disclosures of Protected Health Information Based upon Your Written Authorization:  Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization at any time, in writing, except to the extent that this facility or the practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Others Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to Object

We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then this facility may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your dental care will be disclosed.

Others Involved in Your Healthcare:  Unless you object, this facility may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your dental care. If you are unable to agree or object to such a disclosure, this facility may disclose such information as necessary if it determines that it is in your best interest based on its professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location, general condition or death.

Emergencies: We may use or disclose your protected health information in an emergency treatment situation. If this happens, this facility will try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If this facility is required by law to treat you and it has attempted to obtain your consent but is unable to obtain your consent, it may still use or disclose your protected health information to treat you.

Communication Barriers: We may use and disclose your protected health information if this facility attempts to obtain consent from you but is unable to do so due to substantial communication barriers and it determines, using professional judgment, that you intend to consent to use of disclosure under the circumstances.

Others Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object

We may use or disclose your protected health information in the following situations without your consent or authorization. These situations include:

Required by Law:  We may use or disclose your protected health information to the extent that law requires the use or disclosure. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, as required by law, of any such uses or disclosures.

Public Health: We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. The disclosure will be made for the purpose of controlling disease, injury or disability. We may also disclose your protected health information, if directed by the public health authority, to a foreign government agency that is collaborating with the public health authority.

Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk or contracting or spreading the disease or condition.

Health Oversight: This facility may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations and inspections. Oversight agencies seeking this information include government agencies that oversee the medical care system, government benefit programs, other government regulatory programs and civil rights laws.

Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect. In addition, this facility may disclose your protected health information if it believes that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events, product defects or problems, biological product deviations, and track products, to enable product recalls, to make repairs or replacements, or to conduct post marketing surveillance, as required.

Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), in certain conditions in response to a subpoena, discovery request or other lawful process.

Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include:

• Legal processes and otherwise required by law;
• Limited information requests for identification and location purposes;
• Pertaining to victims of a crime;
• Suspicion that death has occurred as a result of criminal conduct;
• In the event that a crime occurs on the premises of the practice;
• Medical emergency (not on this facility practice’s premises) and it is likely that a crime has occurred.

Coroners: This facility may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law.

Criminal Activity: Consistent with the applicable federal and state laws, this facility may disclose your protected health information if it believes that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. This facility may also disclose protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

Military Activity and National Security:  When the appropriate conditions apply, this facility may use or disclose protected health information of individuals who are Armed Forces personnel:

• For activities deemed necessary by appropriate military command authorities;
• For the purpose of a determination by the Department of Veterans Affairs for your eligibility for benefits;
• To foreign military authority if you are a member of that foreign military services.

This facility may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities, including for the provision of protective services to the President or others legally authorized.

Worker’s Compensation: This facility may disclose your protected health information as authorized to comply with worker’s compensation laws and other similar legally established programs.

Required Uses and Disclosures: Under the law, this facility must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of HIPAA Privacy Rule under §164.500 of the HIPAA Privacy Rule.

2. Your Rights

The following is a statement of your rights with respects to your protected health information and a brief description of how you may exercise these rights.

You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as this facility maintains the protected health information. A “designated record set” contains dental and billing records and any other records that this facility uses for making decisions about you.

Under federal law, however, you may not inspect or copy the following records:

• Information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding;
• Protected health information that is subject to law that prohibits access to protected health information.

Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our HIPAA Officer if you have questions about access to your medical record.

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

This facility is not required to agree to a restriction that you may request. If it believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. If this facility does agree to the requested restriction, it may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with this facility. You may request a restriction by contacting our HIPAA Officer.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our HIPAA Officer.

You may have the right to request this facility to amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for as long as this facility maintains this information. In certain cases, it may deny your request for an amendment. If this facility denies your request for amendment, you have the right to file a statement of disagreement with us and it may prepare a rebuttal to your statement and it will provide you with a copy of any such rebuttal. Please contact our HIPAA Officer if you have questions about amending your medical record.

You have the right to receive an accounting of certain disclosures this facility has made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures this facility may have made to you, to family members or friends involved in your care or for notification purposes. You have the right to receive specific information regarding these disclosures that occurred after April 14, 2003. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations.

You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

3. Complaints

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. You may contact our HIPAA Officer for further information about the complaint process.

4. Effectiveness

This notice was published and becomes effective on April 14, 2003.

Contact Us

8325 Walnut Hill Lane, Suite 111
Dallas, TX 75231