Dr. Michael Ayzin’s Dental Office
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 April 14,
2003, 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.
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.
Appointment Reminders: We may use or disclose
your health information to provide you with appointment reminders
(such as voicemail messages, postcards, or letters).
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 $0.25_ for each
page, $_10.00_ 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: Crystal Reed
Address: 1202 South Bristol Street, Costa Mesa, Ca 92626
© 2002 American Dental Association All Rights Reserved
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Last Modified: April 25, 2003