IMPORTANTNOTICE CONSENT I …
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IMPORTANT NOTICE & CONSENT I AVISO IMPORTANTE Y CONSENTIMIENTO I understand and authorize Big Smiles Pennsylvania P.C. (Provider) and its affiliated dentists or dental hygienists to provide lI1efollolt.;ng services far the named child for whom I am the custodial parent or legal guardian: dental exam & oral hygiene instruction, teeth cleaning, fluoride treatment, x-rays & dental sealants, as well as the application of Silver Diamine Huortde to treat the progression of tooth decay. (The use of Silver Diamine Fluoride may discolor any cavities to a brown or black color.) I also authorize the dentist to fill any cavities or to place a crown over the tooth, extract any problem baby teeth, perform a pulpotomy (treatment of the nerves inside the tooth), place space rnamtainers or perform other dental treatments as needed. I understand that there are risks to dental treatment including swelling or pain that may occur from the treatment or injection of a local anesthetic, or allergic reaction. (For addilional information regarding the risks of treatment and treatment alternatives, please call the number provided.) I authorize & direct Provider to bill & collect payment from any Medicaid, insurance, or other payer. I authorize my chtld's school to make available to Provider and its billing agent my child's insurance information in order to bill payer for services. If I have private dental insurance, I will be billed for & agree to pay any deductibles andlor co pays. Treatment by the in-school dentist may affect future benefits that your child may receive under private insurance, Medicaid or CHIP. Unless I have made pre- arrangements to attend, and am there at lI1e time of service, services will be provided without my presence. (We may send you text messages about the school dental program. Message andlor data fees may be charged by your wireless service provider; to discontinue, reply 'STOP" to any message received from us. You also agree to receive pre-recorded andlor auto-dialed telephone calls relating to the school dental program at the land-hne andlor mobile telephone numbers provided on this consent form.) I have received the Notice of Privacy Practices (NPP) attached to this form and consent to the release of my child's medical record information, including records obtained from other providers, and any HIVIAIDS, communicable disease, sexuallytransmitied disease, drug and alcohol, and anemia information. I authorize release of such information by Provider to any responsible payor and/or administrative service provider and their subcontractors for use and disclosure relating to my child's treatment, payment for services and health care operation purposes. This signed consent authorizes my child's initial and future dental visits. I may withdraw this consent at any time in writing. Entiendo y autorizo a Big Smiles Pennsylvania P.C. (Proveedor) y a sus dentistas afiliados 0 higienistas dental a proveer 105 siguientes servicios al nilio mencionado del cual soy el padre custodio 0 tutor legal: examen dental e instrucciones de higiene oral, Iimpieza dental, tralamiento de fluoruro, rayos-x, sell antes dentales, asi como la aplicaclon de Fluoruro Diamino de Plata para tratar la prooresion de las caries dental. (EI uso de Fluoruro Diamino de Plata puede decolorar cualquier caries a un color rnarron 0 negro.) Tarnbien autorizo al dentista a lIenar cualquier carie 0 colocar una corona sobre el diente, extraer cualquier dientes de leche problernaticos, realizar una endodoncia (tratamiento de los nervi os dentro del diente), colocar mantenedores de espacio 0 realizar otros tratamientos dentales segOn sea necesario. Autorizo al Proveedor a extraer cualquier diente de leche con problema 0 realizar una endodoncia (tratamiento de 105 nervios denlro del diente), como sea necesario. Entiendo que exislen riesgos al recibir tratamientos dentales incluyendo mflamacion 0 dolor que puede ocurrir de la myeccron de la anestesia 0 una reaccion a"~rgica. (Para informacion adicional sobre los riesgos del tratamiento dental y tratamientos altemos por favor lIame al numero proporciooaoa.) Autorizo y dirijo al Proveedor a facturar y recolectar pago de Medicaid, seguro privado 0 tercera persona. Autorizo a la escuela de mi hijo a poner a disposicion del Proveedor y su agente de cobro la informacion del seguro de mi hijo con el fin de cobrar por 105 servicios. Si tengo seguro dental privado, sere facturado y acuerdo a pagar cualquier deducible y/o co-pago. EI tratamiento realizado por el dentista escolar pudiera afectar 105 beneficios de su nino en en un futuro bajo su cobertura privada, Medicaid 0 CHIP. AI menos de qua alia hecho algOn arreglo previamente para atender y estoy ahi al momento de los servicios, el servicio sera proveldo sin mi presencia. (En ocasiones podremos mandarle un texto sobre el programa dental escolar. Cobros de mensaje oly de datos pueden ser aplicados por su proveedor de servicios inalambrico: para descontinuar, responda ·STOP" a cualquier mensaje que reciba de nosotros. Usted tarnblen acepta recibir transmision pre grabada ylo auto lIamadas telefonicas relacionadas con el programa dental escolar a los numeros telefonicos que usted proporciono en esta forma de consentimiento.) He recibido el Aviso de Practices Privadas (NPP} adjuntas a este formulario y el consentimiento para.la divulgacion de la informacion y/a expediente medico de mi hijo, incluyendo los registras obtenidos de otros proveedores, y cualquier otra enfermedad como: VIH/SIDA, enfermedades contagiosas, enfermedades de transmisiOn sexual, drogas, alcohol, y anemia. Yo autorizo la divulqacion de dicha informacion par parte de proveedores para cualquier pagador responsable y/o proveedor de servicios administralivos y de sus subcontratistas para el uso y divulgacion de informacion relacionada con el tratamiento de mi hijo, pago para el mantenimiento y opera cion de cuidado dental. Esta forma de consentimiento firmada autoriza la visita dental inicial y visitas de seguimiento. Puedo retirar mi consentimiento en cualquier momento por escrito. KEEP FOR YOUR RECORDS ELUOT"P. SCHLANG, DOS - GENEP...AL DENTfST, DENTAL DIRECTOR Hsba .!\tfmi. OJ-AD. Daniel Bonnevie. ODS. K<.'!yia Ciccheila. OMD, Megan DiCosl~r;zo. DMD, Samuel Domsky, Ot~tjD, Claire Fieki. ODS, Dwight Fox, DMD. Amy G31a DDS. Rk:h.wj Bensman. DMO. TImothy GOUld. DMD. Ginqer Grieco. DDS, .Shir;ey- Hl:i. DFviO, OfOthi..; !S&.Tli:.1n, Gr\iO, Peter Jackson, DMD, Pat(!c:d Johnson, DMO, Deborah K~hn, Dt~I\D. Jack Lawrence, Ot'l~O, Linda Le w;::;, DDS, ~<'2'yii1 M8SSS'€~!i, O;'.;:D, Robert ;..,..ta:r,~Jell, DDS, .Janice rv1cVsy, DDS, r·/.elante MorrO',..}, D;./.D. Chri",ilno M~I('>.s..DMD, Mi;o:szlav Nemet. DMO, Soomon Peals. DDS. Steven Pesis. DDS, De •..• nis Pe!ricoin. DDS. Mi!ss Rand\., DDS. .Janine Reed, ODS. Elliot Schlaeq, DDS, Amy Scott. OMO. A.1u soree. DDS. Natalia soroeuc. ODS . . ._ Barry Stein. DMO, Usa To:::ldo. o; f.D [ NOTICE OF PRIVACY PPACTiCES THiS NOTICE DESCRiBES HOW MEDICAL iNFORMATiON ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET P.CCESS TO THIS INFORM/',T!Ot-.J PLEASE REViEVV IT CAREFULLY. KEEP FOR YOUR R.ECORDS .---------_._--- -------------- OUR LEGft.L DUTY The privacy of your rni3dic:al ioronnation is il11portani: to us. 'Ne fife required by appticabte federal and state I3'N to m;jn1;;nlhe P';VOCy Ofyour hezJlh infCll"'i'nalio:1. V\le are aiso required 10 WJ'3 you Ulis I\IctiCGebol.!t our priVac.~1practices. our leg;)1 du!ies, ar.:! yourrtghls ccncc-m--ing your hea!th infamoation. \"le rnus~ fclk;1N the p:ivaC'! r.raGi:lcS5 mat are described in this Notice v~'1i!eit is in eiled. VI/e ';.f,1!not1y you jj your unsecured rnedcal inforrnaHon is b••.. eached. We reserve the right to change our privacy practices and the terms of ihis f\lotice at any time, prov;ded such c.:'lc::r.ges are permitted by applicable !2'11. W-c reserve the fight (0 make the changes in our privacy practices and lo,e I)-'SW terms of our Notice effectivefor all health lntormafon that we maintain, including health information we created or receivedbefore we made the changes. Before we mats a sig!lificant change in aur privacy preclicc.=:s, we wil! change this Notice and make 1he new Notice e\vailabie upon request, You may request a copy 01 our Notice at any time. For more information about our privacy practices, or for additional copies of this I\JOl"ic€'. please contact us using the information ~isted at the end Of this Notice. USES AJ--'D DISCLOSURES OF HEr:!-.t TH lNFORMATiON w~ use and disclose health information abou! you for treatment, payment. and heaHhC2re operations. For example: Treatment: Vie may use or disclose vour health information to a physician, school nurse. or ather heallhcare provider providingtreatment to you. f.layment. We may use and disclose your he~tth information to obtain payment for services INe provideto you. H(~aith!:are Operations: We may use and disclose your l1€alth informationin connection ~r-Jtlh our business operations such as revielNing the competence or qualifications of heaHhcare professionals and evaluannq practitioner and provider performance. Your ft.utlwrization: Uses or disclosures not otherwisedescribed in this Notice may be made only wHh your writieil authorization. In addition. we must obtein your written aL!thorization to sell your medical information or to use or oisdoS2 your information for marketing goods or services to you where we are paid to make me communication. ff you glv~ us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitled by your au thorjzatior1' white it was 1!1effect Unlessyou give LIS 3 written authorization. we cannot use or disclose your health il1forma:Jon fOf any re3SOO e:::::cepi those described in this Notice To Your Famil!!' ~nd Friends ana Persons !nvolved in Your {;are: 'We mey disclose your health informa!iol1 to a family member, friEnd or other person involved in YOU( care to the extent necesSSlry to help 1,"Ii!hyour healthcare Qr with payment for YOUi' healthcare. 'liVe may also disclose youI' medical information to dis~s!er relief organizations to help locate individuals during a disasler. We may also .use or disclose your medical ioformation to notify. or@SsLsl: in U1enotiiication, of a family member. a perSOffil representative or a person responsible for YOllf v'Jfe of your locatiol\ general condition or dealh. If you do rot vrant us to disdose YOUi medical information to family members or othel'S in !hesa circumstancas, please notifyour ".PAlI Officer at 883-833·8441. R$quirc-d bV Law: We may use or disciroe yourhealthinfonTlution whenwearerequiredto dosobylaw. Public Safety: We may need to disclose medical information to law enforcement officiels, such as in response to a search warrant or a grand jury subpoena, or to assist law enforcement officials in identifyingor locating an individual,to report deaths thatmayIlaveresultedfromcriminalconduct,andto report criminal conduct on our premises. . Abwse Of Neglect: We may discloseyout health infnrmation.to appropriate auihormf.-s if we I!~asonably belie'/e that YOli are a possible vict!m 01 abuse, np.giect. ordomestic v:o!ence or!he possible v:ctlmofolheraimes.w~may disclose your health informationto the extentnecessary toaverta serious thraat 10 your h:alth or safe~yorthehea~horsafetyof others NaiiCl1al Security; We may disclose your rrn:dical inforrnation tom~ authoriti.:::SofArrTw.d Forcesorforeignmilitarypersonna undGr certain circumsbnc::IS;- to authorized federal offICials for lay,.&fl;l t1teUigence, colAlterintaigence, or oll\er national securit"y activities, and to protect the prf'.s!dent and kl a -:OI72Ctior.a1 institution or law enforcern6flt official having lawful custody 01an inmate or patient under certa'n Qn;oo"'lStar.cr-_~. P'!1polr:~m?nt Reminders: We may use or decrcse yoor beatth infcrmanon to crevice you l:'iilhappcsument reminders (such as voicemad messages. postcards, letters, amahs 0; text tr'ii:~-sages). Haa;f..h.O'lsrsight Aenvrues: VVe rray ruscose bealih inlormation to a health oversight agenc,! for ac::ivi5es authorized by 13W. These (»;erS;ht ac~ss J1dl;de. ([email protected]',at.'tfi5. i~~'f'Qt1::l;jon5, ins{.x;'.:Jicos3r.d )a>.;:S1iF. surveys. Trese a:tivic$ ere r.CC5S:ly fer the qevenvrtent 10mcnltor !he health care system, me O'.Jibreai<of disease gcvEmm~i1! programs, co!11f)iiance wiih c vi rights Ia'o,:ts and to improve pa~ent ootcornss. La'fJ3US and Disputes: We may £fisdos-e he..>Jthinformat.'cn about you in response to a cou:t Of (J~tive order, We may aso disclose health inforn)'3licn about YO',' in response tof) subpoena, di.so:'N~ry request or other lalff:li1 precess. Other Uses and Disdosu:-~-s. As permitted or required by 13W, we rnayusc or dlsdose your medical i'1formaticn Ior research purposes; to organi7..9tions Ih~\ handte and rnonltor Cfgan dcoetien and ~.nsplanlalion; for workers' compensation Of simftar prcqra.. ms (0 comply \"'1itl11mvs rel<::'ltedto workers compensation or simiJar programs that provide bereflts tor work-related jnjL'r.~.s or illness: ror public h:.;.alth~ivrt~~c; such as io prevent Of u:.:n!rot disease. irfury cr <fu~bijI:'J; to report reactions 10madicafions cr prcolerre with products: to notjfy peopla c.(recess of proouos they may be lIS~l"!g; lO roomy a person .••• +hJmay have been exposed to, or is at :isl( for contmc!:ing or spraacioq a disease; to n-edcei exa.rmcss to ideo~ify a deceased ~-OO or deterrnine cause- of death; or to funeraldjrectorslc carryout their duoos. PATl.ErH PJGIiTS Access: You have the righi to k)ok ~I.or getcopies of vOOr heaf.h iilfol!Nl!ion. ""Th 6rn.'ied eKCapuoos. You rnust Il-..akea request in ',',riting kl obtain 3CCGSS toYO<.lrhealih infOfFT'.a~n and fax ycur reaest to tile number at the end 0: fu5 Notce. Diaclcsure ,'>.<::ccur.tirlg: You have the light to receive -3!L~tof sorns disclosures we or (lor business associates have ma-te of your health :,nformation. If you request Ihis accour;tin~Jmore jnan once in a 12~;no.'1Hi period, we may charqe you a reasonable, COSI~b(i=5ed fee for responding tc uiese addi!iorlBi requests, Restrictlcn: YO',I rove the rignt to request thal .•• 'Ie restrict our use (I( dlsdcsue of ycor health inforrnafion. We are not reqlif-OO to eqree to your request except when disclosure '¥'.'OU1d beto your t"P.zlth plan, you {or Somecrle on 'jOCff behalt ceer t/'x=l.n yaaf health plan) has paid in full b'" your h~th care, U"t?c5sdos:ure relates toPayment or l1ealth care operatu.~. and 1M disclO::.-ure is no{ oI.hef\,l,'i$e !"equired by law_ Ii\..-e a9re~ to !he restriction, hO'NB"'6r, we wi~aOOje by that agr~em6m (exr..ept.in an 3margsn::y). Ai~ma'tiv~ Comrru.mi!4iioTl; You M.•. <ethe rigtt. EOrequezl in Io'mting lhQi V.'e cammul1ir..at-: with you about your heclth fntcm1-3- lion by c>..HemalWemeans or toalternative locations sp9diled in yc-ur ",-IIiUenrequest. Amilmirl1err1; You hava !he righi to raquesi that we amend your heatth informalion. Your request must be In \mting and must explain why Lf'je irItormatoo shoold bs am8flded. 'vVe may dcny ymx request l.lIl{!e( certain circumstances. EI~I;~~::m~ NoticG: If you receive this Notice Dr. mlr\l\l{';b site or by eteclrcnic ma~ (e-mail), you are enlillscllo receive «lis N::Jtioo inwr~'tenform \.Ipon requesl QUESTIONS AND COMPLAtNTS , If ycu ",.'ant more inrOOilaoon abOUtO'Jrprivacy prac:\lc;o-s Of have questions or coocems, p!ease contact us. if you are con-.::9Tlad that "'''Ie ;l".ay have vloiated yoli" povacy rights. you may ccoiplain to'.l5 uslr;g tP.econsct information i~.zd at the end of this NaHce. You also may submit a wtiUsn complaint to ihe U.S. D.epattment of Health and Hum<ln Sefvices_ We will net retalia;e in any vkfy if'loo choose to file a compleint ',Yiih us or {he u.s. Depa.r1mel1t 01Heaith snd Human Servees. ConiaCl OffICe(: HiPJl.A OfficE>J Phone: 888-83Hl44 i Fax: 888·330·4331 emajl; [email protected] EffectiveDala: Febr\.talY 1.2018
Transcript of IMPORTANTNOTICE CONSENT I …
IMPORTANT NOTICE & CONSENT I AVISO IMPORTANTE Y CONSENTIMIENTOI understand and authorize Big Smiles Pennsylvania P.C. (Provider) and its affiliated dentists or dental hygienists to provide lI1e follolt.;ng services far the named child for whom I am the custodialparent or legal guardian: dental exam & oral hygiene instruction, teeth cleaning, fluoride treatment, x-rays & dental sealants, as well as the application of Silver Diamine Huortde to treat theprogression of tooth decay. (The use of Silver Diamine Fluoride may discolor any cavities to a brown or black color.) I also authorize the dentist to fill any cavities or to place a crown over thetooth, extract any problem baby teeth, perform a pulpotomy (treatment of the nerves inside the tooth), place space rnamtainers or perform other dental treatments as needed. I understand thatthere are risks to dental treatment including swelling or pain that may occur from the treatment or injection of a local anesthetic, or allergic reaction. (For addilional information regarding the risksof treatment and treatment alternatives, please call the number provided.) I authorize & direct Provider to bill & collect payment from any Medicaid, insurance, or other payer. I authorize my chtld'sschool to make available to Provider and its billing agent my child's insurance information in order to bill payer for services. If I have private dental insurance, I will be billed for & agree to payany deductibles andlor co pays. Treatment by the in-school dentist may affect future benefits that your child may receive under private insurance, Medicaid or CHIP. Unless I have made pre-arrangements to attend, and am there at lI1e time of service, services will be provided without my presence. (We may send you text messages about the school dental program. Message andlordata fees may be charged by your wireless service provider; to discontinue, reply 'STOP" to any message received from us. You also agree to receive pre-recorded andlor auto-dialed telephonecalls relating to the school dental program at the land-hne andlor mobile telephone numbers provided on this consent form.) I have received the Notice of Privacy Practices (NPP) attached to thisform and consent to the release of my child's medical record information, including records obtained from other providers, and any HIVIAIDS, communicable disease, sexuallytransmitied disease,drug and alcohol, and anemia information. I authorize release of such information by Provider to any responsible payor and/or administrative service provider and their subcontractors for use anddisclosure relating to my child's treatment, payment for services and health care operation purposes. This signed consent authorizes my child's initial and future dental visits. I may withdraw thisconsent at any time in writing.
Entiendo y autorizo a Big Smiles Pennsylvania P.C. (Proveedor) y a sus dentistas afiliados 0 higienistas dental a proveer 105 siguientes servicios al nilio mencionado del cual soy el padrecustodio 0 tutor legal: examen dental e instrucciones de higiene oral, Iimpieza dental, tralamiento de fluoruro, rayos-x, sell antes dentales, asi como la aplicaclon de Fluoruro Diamino dePlata para tratar la prooresion de las caries dental. (EI uso de Fluoruro Diamino de Plata puede decolorar cualquier caries a un color rnarron 0 negro.) Tarnbien autorizo al dentista a lIenarcualquier carie 0 colocar una corona sobre el diente, extraer cualquier dientes de leche problernaticos, realizar una endodoncia (tratamiento de los nervi os dentro del diente), colocarmantenedores de espacio 0 realizar otros tratamientos dentales segOn sea necesario. Autorizo al Proveedor a extraer cualquier diente de leche con problema 0 realizar una endodoncia(tratamiento de 105 nervios denlro del diente), como sea necesario. Entiendo que exislen riesgos al recibir tratamientos dentales incluyendo mflamacion 0 dolor que puede ocurrir de lamyeccron de la anestesia 0 una reaccion a"~rgica. (Para informacion adicional sobre los riesgos del tratamiento dental y tratamientos altemos por favor lIame al numero proporciooaoa.)Autorizo y dirijo al Proveedor a facturar y recolectar pago de Medicaid, seguro privado 0 tercera persona. Autorizo a la escuela de mi hijo a poner a disposicion del Proveedor y su agentede cobro la informacion del seguro de mi hijo con el fin de cobrar por 105 servicios. Si tengo seguro dental privado, sere facturado y acuerdo a pagar cualquier deducible y/o co-pago. EItratamiento realizado por el dentista escolar pudiera afectar 105 beneficios de su nino en en un futuro bajo su cobertura privada, Medicaid 0 CHIP. AI menos de qua alia hecho algOn arreglopreviamente para atender y estoy ahi al momento de los servicios, el servicio sera proveldo sin mi presencia. (En ocasiones podremos mandarle un texto sobre el programa dental escolar.Cobros de mensaje oly de datos pueden ser aplicados por su proveedor de servicios inalambrico: para descontinuar, responda ·STOP" a cualquier mensaje que reciba de nosotros. Ustedtarnblen acepta recibir transmision pre grabada ylo auto lIamadas telefonicas relacionadas con el programa dental escolar a los numeros telefonicos que usted proporciono en esta formade consentimiento.) He recibido el Aviso de Practices Privadas (NPP} adjuntas a este formulario y el consentimiento para.la divulgacion de la informacion y/a expediente medico de mi hijo,incluyendo los registras obtenidos de otros proveedores, y cualquier otra enfermedad como: VIH/SIDA, enfermedades contagiosas, enfermedades de transmisiOn sexual, drogas, alcohol, yanemia. Yo autorizo la divulqacion de dicha informacion par parte de proveedores para cualquier pagador responsable y/o proveedor de servicios administralivos y de sus subcontratistaspara el uso y divulgacion de informacion relacionada con el tratamiento de mi hijo, pago para el mantenimiento y opera cion de cuidado dental. Esta forma de consentimiento firmada autorizala visita dental inicial y visitas de seguimiento. Puedo retirar mi consentimiento en cualquier momento por escrito.
KEEP FOR YOUR RECORDSELUOT"P. SCHLANG, DOS - GENEP...AL DENTfST, DENTAL DIRECTOR
Hsba .!\tfmi. OJ-AD. Daniel Bonnevie. ODS. K<.'!yia Ciccheila. OMD, Megan DiCosl~r;zo. DMD, Samuel Domsky, Ot~tjD, Claire Fieki. ODS, Dwight Fox, DMD. Amy G31a DDS. Rk:h.wj Bensman. DMO. TImothy GOUld. DMD. Ginqer Grieco. DDS,.Shir;ey- Hl:i. DFviO, OfOthi..; !S&.Tli:.1n,Gr\iO, Peter Jackson, DMD, Pat(!c:d Johnson, DMO, Deborah K~hn, Dt~I\D. Jack Lawrence, Ot'l~O, Linda Le w;::;, DDS, ~<'2'yii1 M8SSS'€~!i, O;'.;:D, Robert ;..,..ta:r,~Jell, DDS, .Janice rv1cVsy, DDS, r·/.elante MorrO',..}, D;./.D.
Chri",ilno M~I('>.s.. DMD, Mi;o:szlav Nemet. DMO, Soomon Peals. DDS. Steven Pesis. DDS, De •..•nis Pe!ricoin.DDS. Mi!ss Rand\., DDS. .Janine Reed, ODS. Elliot Schlaeq, DDS, Amy Scott. OMO. A.1u soree. DDS. Natalia soroeuc. ODS .. ._ Barry Stein. DMO, Usa To:::ldo. o;·f.D
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NOTICE OF PRIVACY PPACTiCESTHiS NOTICE DESCRiBES HOW MEDICAL iNFORMATiON ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET P.CCESS TO THIS INFORM/',T!Ot-.J
PLEASE REViEVV IT CAREFULLY. KEEP FOR YOUR R.ECORDS.---------_._--- --------------
OUR LEGft.L DUTYThe privacy of your rni3dic:al ioronnation is il11portani: to us. 'Ne fife required by appticabte federal and state I3'N tom;jn1;;nlhe P';VOCy Of your hezJlh infCll"'i'nalio:1. V\le are aiso required 10WJ'3 you Ulis I\IctiCGebol.!t our priVac.~1practices.our leg;)1 du!ies, ar.:! yourrtghls ccncc-m--ing your hea!th infamoation. \"le rnus~ fclk;1N the p:ivaC'! r.raGi:lcS5 mat aredescribed in this Notice v~'1i!e it is in eiled. VI/e ';.f,1!not1y you jj your unsecured rnedcal inforrnaHon is b••..eached.
We reserve the right to change our privacy practices and the terms of ihis f\lotice at any time, prov;ded suchc.:'lc::r.ges are permitted by applicable !2'11. W-c reserve the fight (0 make the changes in our privacy practicesand lo,e I)-'SW terms of our Notice effectivefor all health lntormafon that we maintain, including health informationwe created or receivedbefore we made the changes. Before we mats a sig!lificant change in aur privacypreclicc.=:s, we wil! change this Notice and make 1he new Notice e\vailabie upon request,
You may request a copy 01 our Noticeat any time. For more information about our privacy practices, or foradditional copies of this I\JOl"ic€'. please contactus using the information ~isted at the end Of this Notice.
USES AJ--'D DISCLOSURES OF HEr:!-.t TH lNFORMATiONw~ use and disclose health information abou! you for treatment, payment. and heaHhC2re operations.For example:
Treatment: Vie may use or disclose vour health information to a physician, school nurse. or ather heallhcareprovider providingtreatmentto you.
f.layment. We may use and disclose your he~tth information to obtainpayment for servicesINe provideto you.
H(~aith!:are Operations: We may use and disclose your l1€alth informationin connection ~r-Jtlh our businessoperations such as revielNing the competence or qualifications of heaHhcare professionals and evaluannqpractitioner and provider performance.
Your ft.utlwrization: Uses or disclosures not otherwisedescribed in this Notice may be made only wHh yourwritieil authorization. In addition. we must obtein your written aL!thorization to sell your medical informationor to use or oisdoS2 your information for marketing goods or services to you where we are paid to make mecommunication. ff you glv~ us an authorization, you may revoke it in writing at any time. Your revocationwill not affect any use or disclosures permitled by your au thorjzatior1' white it was 1!1effect Unlessyou giveLIS 3 written authorization.we cannot use or disclose your health il1forma:Jon fOf any re3SOO e:::::cepithosedescribed in this Notice
To Your Famil!!' ~nd Friends ana Persons !nvolved in Your {;are: 'We mey disclose your health informa!iol1 to afamily member, friEnd or other person involved in YOU( care to the extent necesSSlry to help 1,"Ii!hyourhealthcare Qrwith payment for YOUi' healthcare.'liVe may also disclose youI' medical information to dis~s!er relieforganizations tohelp locate individuals during a disasler. We may also .use or disclose your medical ioformation to notify. or@SsLsl:in U1enotiiication,of a family member. a perSOffil representative or a person responsible for YOllf v'Jfe of your locatiol\general condition or dealh. If you do rot vrant us to disdose YOUi medical information to family members or othel'S in!hesa circumstancas, please notifyour ".PAlI Officer at 883-833·8441.
R$quirc-d bV Law: We may use or disciroe your health infonTlution whenwe are required to do so by law.
Public Safety: We may need to disclose medical information to law enforcement officiels, such as inresponse to a search warrant or a grand jury subpoena, or to assist law enforcement officials in identifyingorlocating an individual,to report deaths thatmay Ilave resultedfrom criminalconduct,and to report criminalconducton our premises. .
Abwse Of Neglect: We may discloseyout health infnrmation.to appropriateauihormf.-s if we I!~asonably belie'/e that YOli are apossible vict!m01abuse,np.giect. ordomesticv:o!enceor !hepossible v:ctlmofolheraimes.w~ may disclose your healthinformationto the extentnecessarytoavertaserious thraat 10 yourh:alth or safe~yorthehea~hor safetyofothers
NaiiCl1al Security; We may disclose your rrn:dicalinforrnationtom~ authoriti.:::SofArrTw.d ForcesorforeignmilitarypersonnaundGr certain circumsbnc::IS;- to authorized federal offICials for lay,.&fl;lt1teUigence, colAlterintaigence, or oll\er nationalsecurit"yactivities, and to protect the prf'.s!dent and kl a -:OI72Ctior.a1 institution or law enforcern6flt official having lawful custody 01aninmate or patient under certa'n Qn;oo"'lStar.cr-_~.
P'!1polr:~m?nt Reminders: We may use or decrcse yoor beatth infcrmanon to crevice you l:'iilhappcsument reminders (such asvoicemad messages. postcards, letters, amahs 0; text tr'ii:~-sages).
Haa;f..h.O'lsrsight Aenvrues: VVe rray ruscose bealih inlormation to a health oversight agenc,!for ac::ivi5es authorized by 13W.These (»;erS;ht ac~ss J1dl;de. ([email protected]',at.'tfi5. i~~'f'Qt1::l;jon5, ins{.x;'.:Jicos3r.d )a>.;:S1iF. surveys. Trese a:tivic$ ere r.CC5S:lyfer the qevenvrtent 10mcnltor !he health care system, me O'.Jibreai<of disease gcvEmm~i1! programs, co!11f)iiance wiih c vi rightsIa'o,:ts and to improve pa~ent ootcornss.
La'fJ3US and Disputes: We may £fisdos-e he..>Jth informat.'cn about you in response to a cou:t Of (J~tive order, We mayaso disclose health inforn)'3licn about YO',' in response tof) subpoena, di.so:'N~ry request or other lalff:li1 precess.
Other Uses and Disdosu:-~-s. As permitted or required by 13W, we rnayusc or dlsdose your medical i'1formaticn Ior researchpurposes; to organi7..9tions Ih~\ handte and rnonltor Cfgan dcoetien and ~.nsplanlalion; for workers' compensationOf simftarprcqra..ms (0 comply \"'1itl11mvs rel<::'ltedto workers compensation or simiJar programs that provide bereflts tor work-related jnjL'r.~.sor illness: ror public h:.;.alth~ivrt~~c; such as io prevent Of u:.:n!rot disease. irfury cr <fu~bijI:'J; to report reactions 10madicafions crprcolerre with products: to notjfy peopla c.( recess of proouos they may be lIS~l"!g; lO roomy a person .•••+hJmay have been exposedto, or is at :isl( for contmc!:ing or spraacioq a disease; to n-edcei exa.rmcss to ideo~ify a deceased ~-OO or deterrnine cause- ofdeath; or to funeral djrectors lc carry out their duoos.
PATl.ErH PJGIiTSAccess: You have the righi to k)ok ~I.or getcopies of vOOrheaf.h iilfol!Nl!ion. ""Th 6rn.'ied eKCapuoos. You rnust Il-..akea requestin ',',riting kl obtain 3CCGSS to YO<.lrhealih infOfFT'.a~n and fax ycur reaest to tile numberat the end 0: fu5 Notce.
Diaclcsure ,'>.<::ccur.tirlg: You have the light to receive -3 !L~tof sorns disclosures we or (lor business associates have ma-te ofyour health :,nformation. If you request Ihis accour;tin~Jmore jnan once in a 12~;no.'1Hiperiod, we may charqe you a reasonable,COSI~b(i=5ed fee for responding tc uiese addi!iorlBi requests,
Restrictlcn: YO',I rove the rignt to request thal .••'Ie restrict our use (I(dlsdcsue of ycor health inforrnafion. We are not reqlif-OOto eqree to your request except when disclosure '¥'.'OU1d beto your t"P.zlth plan, you {or Somecrle on 'jOCff behalt ceer t/'x=l.nyaafhealth plan) has paid in full b'" your h~th care, U"t?c5sdos:ure relates toPayment or l1ealth care operatu.~.and 1M disclO::.-ure isno{ oI.hef\,l,'i$e !"equired by law_ Ii\..-e a9re~ to !he restriction, hO'NB"'6r, we wi~aOOje by that agr~em6m (exr..ept.in an 3margsn::y).
Ai~ma'tiv~ Comrru.mi!4iioTl; You M.•.<ethe rigtt. EOrequezl in Io'mting lhQi V.'e cammul1ir..at-: with you about your heclth fntcm1-3-lion by c>..HemalWemeans or to alternative locations sp9diled in yc-ur ",-IIiUenrequest.
Amilmirl1err1; You hava !he righi to raquesi that we amend your heatth informalion. Your request must be In \mting and mustexplain why Lf'je irItormatoo shoold bs am8flded. 'vVe may dcny ymx request l.lIl{!e( certain circumstances.
EI~I;~~::m~NoticG: If you receive this Notice Dr.mlr\l\l{';b site or by eteclrcnic ma~ (e-mail), you are enlillscllo receive «lis N::Jtiooin wr~'tenform \.Ipon requesl
QUESTIONS AND COMPLAtNTS ,If ycu ",.'ant more inrOOilaoon abOUtO'Jrprivacy prac:\lc;o-s Of have questions or coocems, p!ease contact us. if you are con-.::9Tladthat "'''Ie ;l".ay have vloiated yoli" povacy rights. you may ccoiplain to'.l5 uslr;g tP.e consct information i~.zd at the end of thisNaHce. You also may submit a wtiUsn complaint to ihe U.S. D.epattment of Health and Hum<ln Sefvices_ We will net retalia;e inany vkfy if'loo choose to file a compleint ',Yiih us or {he u.s. Depa.r1mel1t 01Heaith snd Human Servees.
ConiaCl OffICe(: HiPJl.A OfficE>J
Phone: 888-83Hl44 i
Fax: 888·330·4331
emajl; [email protected]
EffectiveDala: Febr\.talY 1.2018
