Notice of Privacy Practices for Fishers Oral & Maxillofacial Surgery and Meridian Street Oral &l Maxillofacial Surgery
Effective Date: June 1, 2006
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 all of the records for your care generated by Fishers Oral & Maxillofacial Surgery, and Meridian Street Oral & Maxillofacial Surgery whether made by the Practice or an associated facility.
The Practice provides this Notice to comply with the Privacy Regulations issued by the Department of Health and Human Services in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). We reserve the right to change this notice at any time. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we may receive from you in the future. Each time you visit the Practice for treatment or health care services you may request a copy of the current notice in effect. If you would like to read a more detailed description or our notice, please ask the receptionist.
This notice summarizes our Practice’s policies, which extend to:
- Any health care professional authorized to enter information into your chart (including dentists, physicians, dental assistants, nurses, etc)
- All areas of the Practice (front desk, administration, billing and collection, etc.)
- All employees, staff and other personnel that work for or with our Practice
- Our business associates (including a billing service, or facilities to which we refer patients), on-call dentists and so on.
Your Protected Health Information:
We understand that your medical information is personal to you, and we are committed to protecting the information about you. As our patient, we create paper and electronic medical records about your health, our care for you, and the services and/or items we provide to you as our patient. We need this record to provide for your care and to comply with certain legal requirements.
We are required by law to
- Make sure the protected health information about you is kept private.
- Provide you with a Notice of our Privacy Practices and your legal rights with respect to protected health information about you.
- Follow the conditions of the Notice that is currently in effect.
How we may use and disclose medical information about you:
- 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 medical information about you for services and procedures so they may be billed and collected from you, an insurance company, or any other third party.
- Health Care Operations: We may use and disclose medical information about you so that we can run our Practice more efficiently and make sure that all of our patients receive quality care. This includes quality assessment and improvement activities, reviewing the competence, qualifications, or performance of healthcare professionals, conducting training programs, accreditation certification, licensing or credentialing activities.
- Appointment and Patient Recall Reminders: We may use and disclose medical information to contact you as a reminder that you have an appointment and give instructions for you to follow in preparation for the appointment. This contact may be by phone, in writing, e-mail, or otherwise and may involve the leaving of an e-mail, a message on an answering machine, or otherwise which could (potentially) be received or intercepted by others.
- Required By Law: We will disclose medical information about you when required to do so by federal, state or local law.
- Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. 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. 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.
- Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official.
- Right to inspect and copy: You have the right to inspect and copy medical information that may be used to make decisions about your care. This includes your own medical and billing records, but does not include psychotherapy notes. Upon proof of an appropriate legal relationship, records of others related to you or under your care (guardian or custodial) may also be disclosed. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances.
- Right to Amend: If you feel that the medical information we have about you in your record is incorrect or incomplete, you may ask us to amend the information. We may deny your request under certain circumstances.
- Right to an Accounting of Disclosures: You have the right to request an ?accounting of disclosures.? Your request must state a time period not longer than six (6) years back and may not include dates before 5/1/06.
- Right to request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care (a family member or friend).
We are not required to agree to your request and we may not be able to comply with your request.
If we do agree, we will comply with your request except that we shall not comply, even with a written request, if the information is excepted from the consent requirement or we are otherwise required to disclose the information by law.
- Right to request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. We will accommodate all reasonable requests. Your request must specify how or where you wish us to contact you.
- Right to 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 or the detailed 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.
Authorization: Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission, unless those uses can be reasonably inferred from the intended uses above. If you have provided us with your permission to use or disclose medical 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 information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.
Complaints: If you believe your privacy rights have been violated, you may file a complaint with Fishers Oral & Maxillofacial Surgery, Meridian St. Oral & Maxillofacial Surgery or with the Secretary of the Department of Health and Human Services. To file a complaint with the Practice, contact our Compliance Officer at 317-846-3667 (Fishers) or 317-931-3299 (Meridian St.), who will direct you on how to file an office complaint. All complaints must be submitted in writing, and all complaints shall be investigated, without repercussion to you.
Please download and fill out our Consent Form. After you have completed the form, please make sure to bring it on your first visit to our office. The security and privacy of your personal data is one of our primary concerns and we have taken every precaution to protect it.