Health Insurance Portability and Accountability Act of 1996
Notice of Privacy Practices
Effective: April 14, 2003
Last Modified: June 27, 2016
This notice describes how medical and/or dental information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
If you have any questions about this Notice, please contact our Privacy Officer at the number listed at the end of this Notice. Each time you visit a healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, a plan for future care or treatment, and billing related information. This Notice applies to all of the records of your care generated by your healthcare provider.
Synergy Periodontics and Implants is required by law to maintain the privacy of your health information and to provide you with a description of our legal duties and privacy practices regarding your health information. The current Notice will be available in the office and on our website: www.periosynergy.com
We request you acknowledge with your signature the form on the website or one provided to you in the office.
We are required by law to abide by the terms of this Notice and notify you if we make changes to this Notice, which may be at any time. Changes to the Notice will apply to your medical / dental information that we already maintain as well as new information received after the change occurs. If we change our Notice, it will be posted in the reception area. You may also request that a revised Notice be sent to you in the mail or you may ask for one at your next appointment or appropriate visit. This Notice will also serve to advise you as to your rights with regard to your medical / dental information.
How We May Use and Disclose Medical / Dental Information About You:
The following categories describe examples of the way we use and disclose medical / dental information.
We may use medical / dental information about you to provide, coordinate and manage your treatment or services. We may disclose medical / dental information about you to other doctors, nurses, technicians (e.g. clinical laboratories or imaging companies), or other personnel who are involved in your care. We may communicate your information either orally, in writing by mail, facsimile or email. We may also provide a subsequent healthcare provider with copies of various reports that should assist him or her in treating you.
We may use and disclose medical / dental information about your treatment and services to bill and collect payment from you, your insurance company or a third party payer.
For Health Care Operations:
We may use or disclose, as needed, your health information in order to support our business activities. These activities may include, but are not limited to quality assessment activities, employee review activities, licensing, legal advice, accounting support, information systems support and conducting or arranging for other business activities. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment by telephone, reminder card, email or text message.
There are some services provided in our organization through contracts with business associates. Examples include software support and shredding. If these services are contracted, we may disclose your health information to our business associate so that they can perform the job that we have asked them to do. To protect your health information, however, we require the business associate to appropriately safeguard your information through a written contract.
Other Permitted and Required Uses and Disclosures that May be Made with Your Consent, Authorization or Opportunity of Object:
We also may use and disclose your health information as set forth below, you have the opportunity to agree or object to the use or disclosure of all or part of your health information in these instances. If you are not present or able to agree or object to the use or disclosure of the health information (such as in an emergency situation), then you clinician may, using professional judgment, determine whether the disclosure is in you best interest. In this case, only the information that is relevant to your healthcare will be disclosed.
Individuals Involved in Your Care or Payment for Your Care:
Unless you object, we may release medical / dental information about you to a friend or family member who is involved in your medical / dental care or who helps you pay for your care. In addition, we may disclose medical / dental information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
We may communicate to you via newsletters, mailings, email or other means regarding treatment options, information on health-related benefits or services, to remind you that you have an appointment for dental care; or other community based initiatives of activities in which our facility is participating. If you are not interested in receiving these materials, please contact our Privacy Officer.
Law Enforcement / Legal Proceedings:
We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena or court order.
Your Health Information Rights:
Although your health record is the physical property of the practice that compiled it, you have the right to:
Inspect and Copy: you have the right to inspect and copy medical / dental information that may be used to make decisions about your care. We ask that you submit your request in writing. Requests for access to and copies of your medical / dental information must be submitted in writing. Synergy Periodontics and Implants reserves the right to charge an administrative fee of up to $275 per records release.
Amend: if you feel that the medical / dental information we have about you is incorrect or incomplete, you may ask us to amend the information by submitting a request in writing. You have the right to request an amendment for as long as we keep the information. We may deny your request for an amendment and if this occurs, you will be notified of the reason for the denial.
Request Restrictions: you have the right to request a restriction of limitation of the medical / dental information we use or disclose about you for treatment, payment or healthcare operations. You also have the right to request a limit on the medical / dental information we disclose about you to someone who is involved in your care of the payment for your care, like a family member or friend. For example, you could ask that we not use or disclose information about a procedure that you had. We ask that you submit these requests in writing. We are not required to agree with your request. If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
Request Confidential Communications: you have the right to request that we communicate with you about medical / dental matters in a certain way or at a certain location. We will agree to the request to the extent that it is reasonable for us to do so. For example, you can ask that we use an alternative address for billing purposes. We ask that you submit these requests in writing.
A Paper Copy of this Notice: you have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
To exercise any of your rights, please obtain the required forms from the practice and submit your request in writing to the practice Privacy Officer indicated below.
Complaints: if you believe your privacy rights have been violated, you may file a complaint with us by calling (540) 373-3066 and asking for the Privacy Officer or by contacting the Secretary of the Federal Department of Health and Human Services by calling 1-800-368-1019, or by contacting the Office of Civil Rights regional office. All complaints must be also submitted in writing within 180 days of when you knew that the act or omission complained of occurred. You will not be penalized for filing a complaint.
Other Uses of Medical Information: other uses and disclosures of medical / dental information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical / dental information about you, you may revoke that permission, in writing, at any time. If you revoke your permission we will no longer use or disclose medical / dental information about you for the reasons covered by your written authorization. However, we are unable to take back any disclosures we have already made with your permission and we are required to retain our records of the care that we provided you.
Privacy Officer: Amy
Telephone number: (540) 373-3066