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. If you have any questions about this notice, please contact Dr. Paul Nagode, DDS, 6075 Lake Forrest Drive NW, Sandy Springs, GA 30328; email@example.com, 404-303-1199 phone or 404-303-1667 fax.
WHO WILL FOLLOW THIS NOTICE: This notice describes the information privacy practices followed by our employees, staff and other personnel.
YOUR HEALTH INFORMATION: This notice applies to the information and records we have about you, your health, health status, and the health care and services you receive from Paul D. Nagode, DDS Family Dentistry. Your health information may include information created and received by Paul D. Nagode, DDS Family Dentistry may be in the form of written or electronic records or spoken words, and my include information about your health history, health status, symptoms, examinations, test results, diagnosis, treatments, procedures, prescriptions, related billing activity and similar types of health related information. We are required by law to give you this notice. It will tell you about the ways in which we may use and disclose health information about you and describes your rights and our obligations regarding the use and disclosure of that information.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION: The following describes the ways we may use and disclose your health information.
For Treatment. We may use and disclose health information for your treatment and to provide you with treatment related health care services. For example, we may disclose health information to doctors, nurses, technicians, staff, or other personnel, including people outside our office who are involved in and need the information to provide your medical care, such as pharmacies filling a prescription and other health care provider offices.
For Payment. We may use and disclose health information so that we or others may bill and receive payment from you, an insurance company or a third party for the treatment and services you received. For example, we may give your health plan information about your future treatment to receive prior approval or payment.
For Health Care Operations. We may use and disclose health information for health care operations purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and to operate and manage our office. For example, we may use and disclose information to make sure the dental care you receive is of the highest quality. We also may share information with other entities that have a relationship with you (referral physicians, your health plan) for their health care operation activities.
Appointment Reminders, Treatment Alternatives and Health Related Benefits and Services. We may use and disclose health information to contact you to remind you of an appointment with us. We also may use and disclose health information to tell you about treatment alternatives or health related benefits and services that may be of interest to you.
Individuals Involved in Your Care or Payment for Your Care. When appropriate, we may share health information with a person who is involved in your medical care or payment for your care, such as your family or a close friend. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.
As Required by Law. We will disclose health information when required to do so by international, federal, state or local law.
To Avert a Serious Threat to Health or Safety. We may use and disclose health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may be able to help prevent the threat.
Business Associates. We may disclose health information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.
Military and Veterans. If you are a member of the armed services, or part of the national security or intelligence communities, we may be required by military command or other government authorities to release health information about you. We may also release information about foreign military personnel to the appropriate foreign military authority.
Workers Compensation. We may release health information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks. We may disclose health information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using, a person who may have been exposed to a disease or may be at risk for contacting or spreading a disease or condition, and the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
Health Oversight Activities. We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Data Breach Notification Purposes. We may use or disclose your protected health information to provide legally required notices of unauthorized access to or disclosure of your health information.
Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose health information in response to a court or administrative order. We also may disclose health information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Law Enforcement. We may release health information if asked by a law enforcement official if the information is (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person’s agreement; (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our premises; and (6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.
Coroners, Medical Examiners and Funeral Directors. We may release health 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 also may release health information to funeral directors as necessary for their duties.
Information not Personally Identifiable. We may use or disclose health information about you in a way that does not personally identify you or reveal who you are.
USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO OBJECT
Family and Friends. Unless you object, we may disclose to your family, a relative or a close friend or any other person you identify, your Protected Health Information if we can infer from the circumstances, based on our professional judgment that you would not object. For example, we may assume you agree to our disclosure of your personal health information to your spouse when you bring your spouse with you into the exam room or office during treatment or while treatment is discussed. In situations where you are not capable of giving consent (because you are not present or due to your incapacity or medical emergency), we may, using our professional judgment, determine that a disclosure to your family member or friend is in your best interest. In that situation, we will disclose only health information relevant to the person’s involvement in your care. For example, we may inform the person who accompanied you that you needed emergency treatment and provide updates on your progress and prognosis. We may also use our professional judgment and experience to make reasonable inferences that it is in your best interest to allow another person to act on your behalf to pick up, for example, filled prescriptions, medical supplies, or x-rays.
Disaster Relief. We may disclose your Protected Health Information to disaster relief organizations that seek your Protected Health Information to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can do so.
OTHER USES AND DISCLOSURES OF HEALTH INFORMATION
We will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific, written authorization. The following uses and disclosures of your Protected Health Information will be made only with your written or verbal consent:
1. For our Marketing Purposes. This does not include face-to-face communication about products or services that have benefited you and about prescriptions you have already been prescribed.
2. For the purpose of selling your health information. We may receive payment for sharing your information for, as an example, public health purposes, research, and releases to you or others you authorize a release to, as long as payment is reasonable and related to the cost of providing your health information.
You have the following rights regarding health information we have about you:
Right to Inspect and Copy. You have a right to inspect and copy Health Information that may be used to make decisions about your care or payment for your care. To inspect and copy this health information, you must make your request, in writing, to Dr. Paul Nagode. We have up to 30 days to make your health information available to you and we may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state or federal needs-based benefit program. We may deny your request in certain limited circumstances, however, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial, and we will comply with the outcome of the review.
Right to an Electronic Copy of Electronic Medical Records. If your health information is maintained in an electronic format, you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your health information in the form or format you request, if it is readily producible in such form or format. If it is not, your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.
Right to Get Notice of a Breach. You have the right to be notified upon a breach of any of your unsecured health information.
Right to Amend. If you feel that health information we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our office. To request an amendment, you must make your request, in writing, to Dr. Paul Nagode.
Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we made of health information for purposes other than treatment, payment and health care operations or for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to Dr. Paul Nagode.
Right to Request Restrictions. You have the right to request a restriction or limitation on the health information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the health information we disclose to someone involved in your care of the payment for your care, like a family member or friend. To request a restriction, you must make your request, in writing, to Dr. Paul Nagode. We are not required to agree to your request unless you are asking us to restrict the use and disclosure of your protected health information to a health plan for payment or health care operation purposes and such information you wish to restrict pertains solely to a health care item or service for which you have paid us ‘out-of-pocket” in full. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
Right to Request Confidential Communications. You have the right to request that we communicate with you about medical maters in a certain way or at a certain location. For example, you can ask that we only contact you by mail or at work. To request confidential communications, you must make your request, in writing, to Dr. Paul Nagode. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests.
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 at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our web site, www.greatsmilesga.com. To obtain a paper copy of this notice, contact Dr. Paul Nagode.
CHANGES TO THIS NOTICE:
We reserve the right to change this notice and make the new notice apply to health information we already have as well as any information we receive in the future. We will post a copy of our current notice at our office. The notice will have the effective date on the first page, in the top right-hand corner.
If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact Dr. Paul Nagode. All complaints must be made in writing. You will not be penalized for filing a complaint.