NOTICE OF PRIVACY PRACTICES
THE NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOUR FAMILY MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR FAMILY’S HEALTH INFORMATION IS IMPORTANT TO US.
OUR LEGAL DUTY
We are required by applicable Federal and State Law to maintain the privacy of your family’s health information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your family’s health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003, and will remain in effect until we replace it.
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 significant changes in our privacy practices, we will change this Notice 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 this 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 your family for treatment, payment, and healthcare operations. For example:
Treatment: We may use or disclose your family’s health information to a physician or dentist or other healthcare provider providing treatment to your family.
Payment: We may use and disclose your family’s health information to obtain payment for services we provided for you.
Healthcare Operations: We may use and disclose your health information in connections with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance.
Your Authorization: In addition to our use of health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information 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 is in effect. Unless you give us written authorization, we cannot disclose your family’s health information for any reason except those described in this Notice.
To Your Family and Friends: We must disclose your family’s health information to you as described in the Patient Rights section of this notice. We may disclose your family’s health information to another family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.
Persons Involved In Care: We may use or disclose your family’s 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 family’s care, of the location, the general condition, or death. If you are present, then prior to use or disclosure of your healthcare 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 family’s healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other form of health information.
Market Health-Related Services: We will not use your family’s health information for marketing communications without your written authorization.
Required By Law: We may use or disclose your family’s health information when we are required to do so by law.
Appointment Reminders: We may use or disclose your family’s health information to provide you with appointment reminders (such as voicemail messages, postcards or letters).
Abuse or Neglect: We may disclose your family’s health information to appropriate authorities if we reasonably believe that a member is a possible victim of abuse, neglect or domestic violence or the possible victim of other crimes. We may disclose your family health information to the extent necessary to avert a serious threat to your family’s health or safety of the health or safety of others.
National Security: We may discuss to military authorities the health information of Armed Forced personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement officials having lawful custody of protected health information of inmate or patient under certain circumstances.
Access: You have the right to look at or get copies of your family’s health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee in accordance with Georgia Law 31-33-3 (a) (b) for expenses such as copies and staff time and fees or postage. You may also request access by sending a letter to the address at the end of this Notice.
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your family’s health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last six 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 additional requests.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your family’s health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
Alternative Communications: You have the right to request that we communicate with you about your family’s health information by alternative means or locations. (You must make your request in writing). Your request must specify the alternative means or location, and provide satisfactory explanation on how payments will be handled under the alternative means or location of your request.
Amendment: You have the right to request that we amend your family’s health information. (Your request must be in writing, and it must explain whey the information should be amended). We may deny your request under certain circumstances.
Electronic Notice: If you receive this Notice on our website or by electronic (e-mail), you are entitled to receive this notice in written form.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us.
If you are concerned that we may have violated your family’s privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your family’s health information or to have us communicate with you by alternative means or at alternative locations, you may send complaint to us using the contact information listed at the end of this Notice. You also may 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 family’s 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.
My Kids’ Dentists – Pediatric Dentistry
Contact Officer: Michael Morceau Telephone: 770-926-3400 Fax: 770-924-6317 Email: email@example.com Address: 205 Hawkins Store Road NW, Suite 100 Kennesaw, GA 30144-6215
© 2010 American Dental Association, All Rights Reserved.
Disclaimer and Terms of Website Use
Information that appears on MyKidsDentists.com is not a substitute for diagnosis and treatment provided by a dentist. Always seek the advice of your pediatric or family dentist. Links available on this web site are offered to help our site visitors find information to expand their dental knowledge and in no way should be considered equivalent to an face-to-face consult with your child's dental care professional. My Kids' Dentists has no control over content on any sites we may link to, nor do we vouch for the accuracy of information they contain.
COPYRIGHTS & TRADEMARKS:
My Kids' Dentists maintains a directory of pediatric dental products that may include information you submit via our web site. MyKidsDentists.com may use your contact information to alert you to new information, products and services, events and other opportunities.
With respect to your e-mail address: We have instituted stringent reviews and opt-out capabilities to ensure that you do not receive unwanted e-mail from MyKidsDentists.com We will not give or sell your e-mail address to any entity.
To help us keep our promise to respect your privacy, it is important when you wish to exercise your rights that you contact us.
If you do not want to receive e-mail, postal mail, telephone calls or faxes from us in the future, or if you do not want us to share your contact information in the manner described above, please provide us with your exact name, e-mail and postal addresses, phone and fax numbers. We will no longer use information you so identify and secured via MyKidsDentists.com, if that is your wish.
You may also contact us if you believe your information is being used for purposes other than those for which it was originally collected.