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.

Scope of Notice

This Notice applies to all records of your care generated or received by us, which may include information about your condition or treatment, diagnostic tests and images, and related dental or other health information.

Our Responsibilities

We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We must follow the privacy practices that are described in this Notice while it is in effect.

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.

How We May Use and Disclose Your Health Information

The following categories describe the different ways that we may use and disclose your health information without your permission:

Treatment

We may use and disclose your health information for your treatment. For example, we may disclose your health information to a specialist providing treatment to you.

Payment

We may use and disclose your health information to obtain reimbursement for the treatment and services you receive from us or another entity involved with your care. Payment activities include billing, collections, claims management, and determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party. For example, we may send claims to your dental health plan containing certain health information.

Healthcare Operations

We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, conducting training programs, reviewing the competence and qualifications of healthcare professionals, and licensing activities.

Business Associates

We may disclose your health information to one or more of our business associates in order for them to provide services to us or on our behalf pursuant to a written business associate agreement. Our business associates are required to establish reasonable and appropriate safeguards to protect your information.

Individuals Involved in Your Care or Payment for Your Care

We may disclose your health information to your family or friends or any other individual identified by you when they are involved in your care or in the payment for your care. Additionally, we may disclose information about you to a patient representative. If a person has the authority by law to make health care decisions for you, we will treat that patient representative the same way we would treat you with respect to your health information.

Required by Law

We may use or disclose your health information when we are required to do so by law, such as to report suspected abuse or neglect.

Public Health Activities

We may disclose your health information for public health activities, such as to prevent or control disease, injury or disability, report child abuse or neglect, or notify a person of a recall, repair, or replacement of products or services.

Health Oversight Activities

We may disclose your health information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, and licensure actions.

Law Enforcement

We may disclose your health information for law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order.

Judicial and Administrative Proceedings

If you are involved in a lawsuit or a dispute, we may disclose your health information in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process instituted by someone else involved in the dispute, but only if efforts have been made, either by the requesting party or us, to tell you about the request or to obtain an order protecting the information requested.

Disaster Relief

We may use or disclose your health information to assist in disaster relief efforts.

Serious Threat to Health or Safety

We may disclose your health information when permitted by law to avert a serious and imminent threat to the health or safety of a person or the public.
Specialized Government Functions. To the extent applicable, we may release your health information for specialized government functions, including military and veterans activities, national security and intelligence activities, and correctional institutions.

Worker’s Compensation

We may disclose your health information to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law.

Coroners, Medical Examiners, and Funeral Directors

We may release your information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose your health information to funeral directors consistent with applicable law to enable them to carry out their duties.
Fundraising. We may contact you to provide you with information about our sponsored activities, including fundraising programs, as permitted by applicable law. If you do not wish to receive such information from us, you may opt out of receiving the communications.

Other Uses and Disclosures of PHI

Most uses and disclosures of psychotherapy notes, uses and disclosures of health information for marketing purposes, and disclosures that constitute a sale of health information will be made only with your written authorization. Similarly, most disclosures of alcohol and substance abuse records, mental health records and information related to the results of HIV/AIDs tests will be made only with your written authorization. In any other situation not identified in this Notice, we will ask for your written authorization before using or disclosing information about you. You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your health information, except to the extent that we have already taken action in reliance on the authorization.

Your Health Information Rights

Right to Access

You have the right to inspect or get copies of your health information, with limited exceptions, as provided by 45 CFR § 164.524. You must make the request in writing at the address listed at the end of this Notice. If you request information that we maintain on paper, we may provide photocopies. If you request information that we maintain electronically, you have the right to an electronic copy. We will use the form and format you request if readily producible. We will charge you a reasonable cost-based fee for the cost of supplies and labor of copying, and for postage if you want copies mailed to you. If you are denied a request for access, you have the right to have the denial reviewed in accordance with the requirements of applicable law.

Right to Request Amendment

You have a right to request that we amend your health information if you believe the information is not accurate or is incomplete, as provided by 45 CFR § 164.526. To request an amendment of your health information, you must submit your request in writing to the address listed at the end of this Notice. Your request must explain why the information should be amended. We may deny your request under certain circumstances.
Right to an Accounting of Disclosures. You have a right to receive an accounting of certain disclosures of your health information, as provided by 45 CFR § 164.528. To request an accounting of disclosures of your health information, you must submit your request in writing to the address listed at the end of this Notice.

Right to Request a Restriction

You have the right to request additional restrictions on certain uses and disclosures of your health information for treatment, payment or health care operations, as provided by 45 CFR § 164.522(a). You must make your request in writing. We are not required to agree to your request, except in the case where the disclosure is to a health plan for purposes of carrying out payment or health care operations, and the information pertains solely to a health care item or service for which you, or a person on your behalf (other than the health plan), has paid our practice in full.

Right to Alternative Communication

You have the right to request that we communicate with you about your health information by alternative means or at alternative locations, as provided by 45 CFR § 164.522(b). You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request. We will accommodate all reasonable requests. However, if we are unable to contact you using the ways or locations you have requested we may contact you using the information we have.

Right to a Paper Copy of this Notice

You have a right to obtain a paper copy of this Notice upon request.

Changes to this Notice

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, and to make new Notice provisions effective for all protected health information that we maintain. When we make a significant change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at our practice location, and we will provide copies of the new Notice upon request.

Complaints or Request for More Information

If you want more information about our privacy practice, please contact us as the address below. If you believe your privacy rights may have been violated, you can file a complaint with the Privacy Officer listed below or with the Office for Civil Rights, U.S. Department of Health and Human Services. You will not be penalized in any way for filing a complaint.

Privacy Officer: Robert Smith DMD

Telephone: 615.800.6133

E-mail: drsmith@smithdentalnashville.com