HIPAA Disclosure

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 applies to services furnished by the dentists, dental hygienists and other personnel of Winchendon Family Dental. As of April 14th, 2003, we are required under the Health Insurance Portability and Accountability Act (HIPAA) and Massachusetts law to maintain the privacy of your health information and to provide you with this Notice of Privacy Rights & Practices.

This document explains in detail how we uses your Protected Health Information (“PHI”). PHI is any information about you that could identify you and your past, present, or future physical or mental health condition(s). Your acknowledgement of receipt of this document will be required the first time you receive services after April 14th, 2003 by the Practice.

I. USE AND DISCLOSURE FOR TREATMENT, PAYMENT, AND OPERATIONAL PURPOSES:

We may use, and with your consent disclose, your PHI for the following purposes:

Treatment – we keep a record of each visit and/or admission. These records may include your test results, diagnoses, medications or other therapies. In addition, we may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to your.

Payment – we maintain a record of and may use information related to services and supplies you receive at each visit and/or admission so that we can be paid by you, and insurance company, or a third party. We may tell your health plan and other payors about an upcoming treatment or service which requires their prior approval and authorization.

Health Care Operations – we use your medical informtion to improve the services we provide, to train staff and students, for business management, and for customer service purposes.

II. USE AND DISCLOSURE WITHOUT AUTHORIZATION OR CONSENT:

A. There are additional times when we are permitted or required to use or disclose medical information without your written authorization or consent. These circumstances are listed below:

In emergency treatment situations

To assist incommunicative patients

To protect victims of abuse, neglect or domestic violence

For health oversight activities such as fraud investigations

To Workers’ Compensation if you are injured at work

To coroners, medical examiners and funeral directors

To avert serious threat to public health or safety

If required by law

For law enforcement

For public health activities (tracking diseases or medical devices)

For certain judicial or administrative proceedings

For government functions such as national security & intelligence

To a correctional institution if you are an inmate

B. We may also disclose PHI (other than Highly Confidential Information described in Section III below) to a family member, relative or friend – or anyone else you identify – as follows: (i) when you are present for, or otherwise available prior to, the disclosure, and do not object to such disclosure after being given the opportunity to do so; (ii) when you are incapacitated or in an emergency situation if, in the exercise of our professional judgement and in our experience with common practice, we determine that the disclosure is in your best interests. In these cases we will only disclose the PHI that is directly relevant to the person’s involvement in your health care or payment related to your health care.

III. AUTHORIZATION

Except as otherwise permitted by law, all other uses and disclosures not described above will require your signed authorization. You may revoke any authorization you provide at any time by delivering a written statement directly to the Privacy Officer, except to the extent that we have already taken action in reliance on your authorization.

IV. NOTICE OF PRIVACY RIGHTS & PRACTICES

Please know that federal and state law requires special privacy protections for certain highly confidential information about you including, but not limited to:
1.) alcohol and drug abuse prevention, treatment and referral, 2.) HIV/AIDS testing, diagnosis or treatment, 3.)venereal disease(s), 4.) genetic testing, 5.) research involving controlled substances. In order for us to disclose your Highly Confidential Information for a purpose other than those permitted by law, we must obtain your written consent and/or authorization.

YOUR RIGHTS

Under HIPAA, you have the right to request in writing:

Restrictions on how we use or disclose your medical information.
Confidential communications to an alternate phone or address other than your home.
Access to your medical information to review and obtain a copy, subject to federal and state laws (fees may apply).
An amendment to your medical information if you feel you or your health care provider need to make additions or corrections.
An accounting of disclosures of your medical information for purposes other than treatment, payment, health care operations or made pursuant to an authorization.
A paper copy of this notice even if you have received it electronically.
A revocation of any specific authorization obtained in connection with your privacy, such as for marketing and research.

While we will consider all requests for privacy restrictions carefully, we are not required to agree to any requested restrictions.

OUR RESPONSIBILITIES

We are required by law to maintain the privacy of your medical information, to provide you with this written Notice of Privacy Rights and Practices, and to abide by the terms of the Notice currently in effect. We reserve the right to change this Notice an our privacy practices and make the new provisions effective for all information we maintain. Revised Notices will be posted in our facilities and offices, and will be available from your direct treatment provider.

FOR MORE INFORMATION

If you would like further information about your privacy rights, are concerned that we have violated your privacy rights or disagree with ta decision that we have made about access to your PHI, you may contact our Privacy Officer at the address or phone number below. You may also file written complaints with the Director, Office for Civil Rights of the U.S. Department of Health and Human Services. Upon request, the Privacy Officer will provide you with the correct address for the Director. We will not retaliate against you if you file a complaint with use of with the Director.