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 June 11, 2022, 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; any changes to our privacy practices or the new terms of our Notice will be 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 (“TPO”). For example: Treatment: We may use or disclose your Protected Health
Information (“PHI”, hereinafter referred to as “health information”) to a dentist, dental specialist, pharmacist, physician or any other healthcare provider providing treatment to you. Such disclosures may be made to the staff of such a provider.
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. Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us separate 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 to the extent necessary to help with your healthcare or with payment for your healthcare, and we will disclose health information of an emancipated minor to their parent or legal guardian. Additionally, we may disclose your health information to a 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.
Custodial/Non-Custodial Parents: In Alabama, a custodial and non-custodial parent of a child has equal access to the parents’ child’s health records. Therefore, we will disclose a child’s health information to a parent unless (1) a court has issued an order that limits the non-custodial parent’s right to access to the child’s health records; and (2) we have received a copy of the
court order. 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 internal or external marketing communications without your written authorization. Required or Allowed by Law: We will use or disclose your health information when we are required to do so by law. We will disclose your health information when requested to do so by a coroner or by the personal representative of your estate. If your estate does not have a personal representative then your spouse may make such a request. If you have no spouse then your child may make such a request.
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
Law Enforcement: We may disclose to correctional institutions or law enforcement officials the health information of an inmate or patient in lawful custody under certain circumstances. We will disclose health information when presented with a court order to do so.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages at home, work, or with family members, or by postcard or letter).
Access: If you are at least eighteen (18) years of age, or if less than eighteen (18), you are emancipated; or the parent, guardian, or custodian of a patient who is incompetent has 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 may personally present a request in writing to obtain access to your general health information or, you may request access or copies by mailing us a letter with a notarized signature to the address at the end of this Notice. You may obtain a form to request access by using the contact information listed at the end of this Notice. A written request for general health records is valid for sixty (60) days. We will charge you a reasonable fee for staff time when viewing your records or the statutory fee for copies. The viewing of your records will only take place under office supervision. We will comply with requests to view or obtain copies of records within a reasonable time following the receipt of a proper written request. If you request copies, the statutory rate as of the date of this notice is $15.00 for record retrieval, $0.25 per page copied, actual postage, and a $10.00 surcharge for copies requested to be delivered within 2 working days. Requests for radiographic images are not covered by statute but will be provided at a cost of $12.00 per image copied. Copies will be provided after receipt of payment. Note that the prevailing statutory rate as of the date of request will be charged and that this office is not statutorily required to comply with requests for expedited record delivery. If you request an alternative format, statutory rates do not apply and we will charge a cost-based fee for providing your health information in the requested format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. You may contact us using the information listed at the end of this Notice for further explanation of our fee structure. (Note that certain types of health information, such as communicable diseases, mental health treatment, and drug and alcohol abuse, are designated as “Sensitive Health Records” by Indiana statute requires an additional express authorization in addition to the request for general health information.)
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 July 23, 2012. 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 in writing by mail, e-mail, or fax. 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
Contact Person: William Catanzaro, DMD
Telephone: 256- 400- 3730
Address: 104 Cherry Street, Gadsden, AL 35901
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