ST. JOHNS DENTAL CARE
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
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 effect 04/13/03, 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 a significant change 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 you for treatment, payment, and
healthcare operations. For example:
Treatment: We may use or disclose your health information to a physician
or other healthcare provider 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 quality
assessment and improvement activities, reviewing the competence or
qualifications of healthcare professionals, evaluating practitioner and provider
performance, conducting training programs, accreditation, certification,
licensing or credentialing activities.
Michigan’s Dental Patient Consent Law: We are required by Michigan Law to
obtain your written consent prior to making certain disclosures of your health
information.
Your Authorization: In addition to our use of your health information for
treatment, payment or healthcare 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 any
time. Your revocation will not affect any use or disclosures permitted by your
authorization while it was in effect. Unless you give us a written
authorization, we cannot use or disclose your health information for any reason
except those described in this Notice.
To Your Family and Friends: We must disclose your health information to
you, as described in the Patient Rights section of this Notice. We may disclose
your health information to a 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 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 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 we
are 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, counterintelligence, and other national security activities. We
may disclose to correctional institution or law enforcement official having
lawful custody of protected health information of inmate or patient under
certain circumstances.
Patient Contacts: We may use or disclose your health information to
provide you with appointment reminders (such as voicemail messages, postcards,
folding postcards, letters or electronic reminders such as email). We may use or
disclose your health information to contact you for changes to appointments,
treatment alternative information, account payments/collection procedures, or
other health related benefits or services. They may include voicemail, telephone
messages, postcards, folding postcards, letters or electronic transmission such
as email.
Lab Related Procedures: We may use or disclose your health information
when we forward your treatment cases to our dental lab for fabrication of your
crowns, bridges, partials, dentures and etc. We may use or disclose your health
information to special labs for biopsies or tests.
Other Special Circumstances or Mailings: We may use or disclose your
health information to send you Newsletters, Birthday, Anniversary, Sympathy
Cards, or other card mailings. We may ask you for permission to use your name or
testimonial for treatment you have received.
PATIENT RIGHTS
Access: You have the right to look at or get copies of your 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 for expenses such as copies and staff time. You may
also request access by sending us a letter to the address at the end of this
Notice. If you request copies, we will charge you $.75 for each page, $30.00 per
hour for staff time to locate and copy your health information, and postage if
you want the copies mailed to you. If you request an alternative format, we will
charge a cost-based fee for providing your health information in that format. If
you prefer, we will prepare a summary or an explanation of your health
information for a fee. Contact us using the information listed at the end of
this Notice for a full explanation of our fee structure.)
Disclosure Accounting: You have the right to receive a list of instances
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 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 additional 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, we will abide
by our agreement (except in an emergency).
Alternative Communication: You have the right to request that we
communicate with you about your health information by alternative means or to
alternative locations. {You must make your request in writing.} Your request
must specify the alternative means or location, and provide satisfactory
explanation 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 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 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
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 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 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 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: Office Manager
Telephone: (517) 507-4332 Fax: (989) 224-3277
E-mail: drconnelly@stjohnsdentist.com
Address: 911 E. State St. Suite C, St. Johns, MI 48879
