THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Green Park Dentistry
518 4th Street Southwest
Hickory, NC 28403
Office: (828) 327-7502
Fax: (828) 327-3202
Effective date: September 18, 2023
This is a summary of how we may use and disclose your protected health information and your rights and choices when it comes to your information. We will explain these in more detail on the following pages.
Our Uses and Disclosures
We may use and disclose your information as we:
- Treat you.
- Bill for services.
- Run our organization.
- Do research.
- Comply with the law.
- Respond to organ and tissue donation requests.
- Work with a medical examiner or funeral director.
- Address workers' compensation, law enforcement, or other government requests.
- Respond to lawsuits and legal actions.
You have some choices about how we use and share information as we:
- Communicate with you.
- Tell family and friends about your condition.
- Provide disaster relief.
- Provide mental health care.
- Market our services
You have the right to:
- Get a copy of your paper or electronic protected health information.
- Correct your protected health information.
- Ask us to limit the information we share, in some cases.
- Get a list of those with whom we've shared your information.
- Request confidential communication.
- Get a copy of this privacy notice.
- Choose someone to act for you.
- File a complaint if you believe we have violated your privacy rights.
We respect your privacy. We are also legally required to maintain the privacy of your protected health information (PHI) under the Health Insurance Portability and Accountability Act (HIPAA) and other federal and state laws. We follow state privacy laws when they are stricter or more protective of your PHI than federal law.
As part of our commitment and legal compliance, we are providing you with this Notice of Privacy Practices (Notice). This Notice describes:
- Our legal duties and privacy practices regarding your PHI, including our duty to notify you following a data breach of your unsecured PHI.
- Our permitted uses and disclosures of your PHI.
- Your rights regarding your PHI.
If you have any questions about this Notice, please contact Jason Brown, Privacy Officer
- Is health information about you:
- which someone may use to identify you; and
- which we keep or transmit in electronic, oral, or written form.
- Includes information such as your:
- contact information;
- past, present, or future physical or mental health or medical conditions;
- payment for health care products or services; or
We create a record of the care and dental services you receive, to provide your care, and to comply with certain legal requirements. This Notice applies to all the PHI that we generate.
We follow and our employees and other workforce members follow the duties and privacy practices that this Notice describes and any changes once they take effect.
Changes to this Notice
We can change the terms of this Notice, and the changes will apply to all information we have about you. The new notice will be available on request, in our office, and on our website.
Data Breach Notification
We will promptly notify you if a data breach occurs that may have compromised the privacy or security of your PHI. We will notify you within the legally required time frame.
Uses and Disclosures of Your PHI
The law permits or requires us to use or disclose your PHI for various reasons, which we explain in this Notice. We have included some examples, but we have not listed every permissible use or disclosure. When using or disclosing PHI or requesting your PHI from another source, we will make reasonable efforts to limit our use, disclosure, or request about your PHI to the minimum we need to accomplish our intended purpose.
Uses and Disclosures for Treatment, Payment, or Health Care Operations
- Treatment. We may use or disclose your PHI and share it with other professionals who are treating you, including dentists, physicians, nurses, technicians, medical students, or hospital personnel involved in your care. For example, we might disclose information about your overall health condition to physicians or dentists who are treating you for a specific injury or condition.
- Payment. We may use and disclose your PHI to bill and get payment from health plans or others. For example, we share your PHI with your health insurance plan so it will pay for the services you receive.
- Dental/Healthcare Care Operations. We may use and disclose your PHI to run our practice and improve your care. For example, we may use your PHI to manage the services you receive or to monitor the quality of our dental services.
Other Uses and Disclosures
We may share your information in other ways, usually for public health or research purposes or to contribute to the public good. For more information on permitted uses and disclosures, see www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html. For example, these other uses and disclosures may involve:
- Our Business Associates. We may use and disclose your PHI to outside persons or entities that perform services on our behalf, such as auditing, legal, or transcription (Business Associates). The law requires our business associates and their subcontractors to protect your PHI in the same way we do. We also contractually require these parties to use and disclose your PHI only as permitted and to appropriately safeguard your PHI.
- Legal Compliance. For example, we will share your PHI if the Department of Health and Human Services requires it when investigating our compliance with privacy laws.
- Public Health and Safety Activities. For example, we may share your PHI to:
- report injuries, births, and deaths;
- prevent disease;
- report adverse reactions to medications or medical device product defects;
- report suspected child neglect or abuse, or domestic violence; or
- avert a serious threat to public health or safety.
- Responding to Legal Actions. For example, we may share your PHI to respond to:
- a court or administrative order or subpoena;
- discovery request; or
- another lawful process.
- Research. For example, we may share your PHI for some types of health research that do not require your authorization, such as if an institutional review board (IRB) has waived the written authorization requirement because the disclosure only involves minimal privacy risks.
- Workers' Compensation, Law Enforcement, or Other Government Requests. For example, we may use and disclose your PHI for:
- workers' compensation claims;
- health oversight activities by federal or state agencies;
- law enforcement purposes or with a law enforcement official; or
- specialized government functions, such as military and veterans' activities, national security and intelligence, presidential protective services, or medical suitability.
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, please contact us and we will make reasonable efforts to follow your instructions.
You have both the right and choice to tell us whether to:
- Share information, such as your PHI, general condition, or location, with your family, close friends, or others involved in your care.
- Share information in a disaster relief situation, such as to a relief organization to assist with locating or notifying your family, close friends, or others involved in your care.
We may share your information if we believe it is in your best interest, according to our best judgment, and:
- If you are unable to tell us your preference, for example, if you are unconscious.
- When needed to lessen a serious and imminent threat to health or safety.
Uses and Disclosures that Require Authorization
In these cases, we will only share your information if you give us written permission:
- Marketing our services.
- Selling Data.
- Other uses and disclosures not described in this Notice.
You may revoke your authorization at any time, but it will not affect information that we already used and disclosed.
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
You have the right to:
- Inspect and Obtain a Copy of Your PHI. You have the right to see or obtain an electronic or paper copy of the PHI that we maintain about you (right to request access). Alternatively, you may request a summary of your PHI or an explanation of your PHI. Some clarifications about your access rights:
- we may require you to make access requests in writing;
- we may charge a reasonable, cost-based fee for the costs of copying, mailing, or other supplies associated with your request;
- you may request that we provide a copy of your PHI to a family member, another person, or a designated entity. We require that you submit these requests in writing with your signature, and clearly identify the designated person and where to send the PHI;
- if you request a copy of your PHI, we will generally decide to provide or deny access within 30 days, however, if we cannot act within 30 days, we will give you a reason for the delay in writing and when you can expect us to act on your request; and
- we may deny your request for access in certain limited circumstances, however, if we deny your access request, we will provide a written denial with the basis for our decision and explain your rights to appeal or file a complaint.
- Make Amendments. You may ask us to correct or amend PHI that we maintain about you that you think is incorrect or inaccurate. For these requests:
- you must submit requests in writing, specify the inaccurate or incorrect PHI, and provide a reason that supports your request;
- we will generally decide to grant or deny your request within 60 days. If we cannot act within 60 days, we will give you a reason for the delay in writing and include when you can expect us to complete our decision, which will be no longer than an additional 30 days. We will only ask for an extension once in response to a request;
- we may deny your request for an amendment if you ask us to amend PHI that is not part of our record, that we did not create, that is not part of a designated record set, or that is accurate and complete;
- if we deny your request, we will tell you why in writing. You will have the right to submit a written statement disagreeing with the denial and, if you opt not to submit this statement, you may request that we provide your original request for amendment and the denial with any future disclosures of PHI subject to the amendment. However, we may prepare a written rebuttal to any individual's statement of disagreement; and
- we will append the material created or submitted in accordance with this paragraph to your designated record.
- Request Additional Restrictions. You have the right to ask us to limit what we use or share about your PHI (right to request restrictions). You can contact us and request us not to use or share certain PHI for treatment, payment, or operations or with certain persons involved in your care. For these requests:
- we are not required to agree;
- we may say "no" if it would affect your care; but
- we will agree not to disclose information to a health plan for purposes of payment or health care operations if the requested restriction concerns a health care item or service for which you or another person, other than the health plan, paid in full out-of-pocket, unless it is otherwise required by law.
- Request an Accounting of Disclosures. You have the right to request an accounting of certain PHI disclosures that we have made. For these requests:
- we will respond no later than 60 days after receiving the request. We may ask for an additional 30 days during this 60-day period, but if we do, we will only do it once, provide a written statement of why, and indicate the date by which we intend to send the response;
- we will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures, such as any you asked us to make; and
- we will provide one accounting a year for free, but will charge a reasonable, cost-based fee, if you ask for another one within 12 months. We will notify you about the costs in advance and you may choose to withdraw or modify your request at that time.
- Choose Someone to Act for You. If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your PHI. We will confirm the person has this authority and can act for you before we take any action.
- Request Confidential Communications. You have the right to request that we communicate with you about health matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or at a specific address. For these requests:
- you must specify how or where you wish to be contacted; and
- we will accommodate reasonable requests.
- Make Complaints. You have the right to complain if you feel we have violated your rights. We will not retaliate against you for filing a complaint. You may either file a complaint:
- directly with us by contacting Jason Brown. All complaints must be submitted in writing; or
- with the Office for Civil Rights at the US Department of Health and Human Services. Send a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201 call 1-877-696-6775; or visit www.hhs.gov/ocr/privacy/hipaa/complaints/.
Acknowledgment of Receipt
By signing this document, I acknowledge that I have received a copy of Green Park Dentistry's Notice of Privacy Practices and that I read and understood it. I understand that:
- I have certain rights to privacy regarding my PHI.
- Green Park Dentistry can and will use my PHI for purposes of my treatment, payment, and dental/healthcare operations.
- The Notice explains in more detail how Green Park Dentistry may use and share my PHI for other purposes.
- I have the rights regarding my PHI listed in the Notice.
- Green Park Dentistry has the right to change the Notice from time to time and I can obtain a current copy of the Notice by contacting Jason Brown.