Notice of Privacy Practices
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.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
[PRACTICE LEGAL NAME], doing business as Brightside Oral Surgery ("Practice," "we," "us"), is required by law to maintain the privacy of your protected health information ("PHI"), to provide you with this notice of our legal duties and privacy practices, and to follow the terms of the notice currently in effect.
How We May Use and Disclose Your Health Information
The following describes the ways we may use and disclose health information that identifies you. Not every use or disclosure in a category will be listed; however, all of the ways we are permitted to use and disclose information will fall within one of these categories.
Treatment
We may use your health information and share it with other professionals who are treating you. For example, a doctor treating you for a follow-up care need may need to know about your oral surgery procedure at our practice.
Payment
We can use and share your health information to bill and receive payment from health plans or other entities. For example, we may provide information to your dental insurance carrier to confirm your eligibility and obtain authorization for a procedure.
Health Care Operations
We can use and share your health information to run our practice, improve your care, and contact you when necessary. For example, we use health information about you to manage your treatment, train our staff, and evaluate our performance.
Appointment Reminders and Communications
We may contact you to remind you of an appointment or to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Required by Law
We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy law.
Public Health and Safety
We can share health information about you for certain public health activities and purposes, including reporting suspected child abuse or neglect, preventing or controlling disease, and reporting reactions to medications to the FDA. We may share information if we believe it is necessary to prevent a serious and imminent threat to a person's or the public's health and safety.
Health Oversight Activities
We may disclose health information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, and licensure programs. These activities are necessary for the government to monitor the health care system.
Lawsuits and Legal Proceedings
We can share health information about you in response to a court or administrative order, or in response to a subpoena, provided that efforts have been made to notify you of the request or to obtain an order protecting your information.
Law Enforcement
We may release health information if asked by a law enforcement official in limited circumstances, such as when identifying or locating a suspect or providing information about a victim of a crime.
Workers' Compensation
We may release health information about you for workers' compensation or similar programs as authorized by law.
Your Rights Regarding Your Health Information
You have the following rights regarding health information we maintain about you. To exercise any of these rights, please submit a written request to our Privacy Officer at the address below.
Right to Inspect and Copy
You have the right to inspect and obtain a copy of health information that may be used to make decisions about your care, including medical and billing records. We may charge a reasonable fee for providing a copy. We may deny your request under limited circumstances.
Right to Amend
If you believe that health information we have about you is incorrect or incomplete, you may ask us to amend it. We may deny your request if the information was not created by us, is not part of the information we maintain, or is already accurate and complete.
Right to an Accounting of Disclosures
You have the right to request a list of disclosures we have made of your health information, other than disclosures for treatment, payment, or health care operations and certain other exceptions. We will provide one accounting per 12-month period free of charge.
Right to Request Restrictions
You have the right to request a restriction or limitation on the health information we use or disclose for treatment, payment, or health care operations. We are not required to agree to your request except in the case of a restriction on disclosure to a health plan if you have paid out-of-pocket in full for the service.
Right to Request Confidential Communications
You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you may ask that we contact you only at work or by mail. We will accommodate all reasonable requests.
Right to a Paper Copy of This Notice
You have the right to receive a paper copy of this notice at any time, even if you have agreed to receive the notice electronically.
Our Duties
We are required by law to maintain the privacy of your health information and to provide you with this notice. We must follow the duties and privacy practices described in the notice currently in effect and will let you know promptly if a breach occurs that may have compromised your information.
We reserve the right to change the terms of this notice and make the new notice provisions effective for all health information that we maintain. We will post a copy of the current notice in our office and on our website. The new notice will be effective for all protected health information that we maintain at that time.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, contact our Privacy Officer at the address or phone number below. You will not be penalized for filing a complaint.
Contact Our Privacy Officer
[PRIVACY OFFICER NAME/TITLE]
Brightside Oral Surgery
5682 S 3500 W, Suite 200
Roy, UT 84067
Phone: (801) 555-1212