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 - THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US
Your protected health information (i.e., individually identifiable information, such as names, dates, phones/fax numbers, email addresses, home addresses, social security numbers, and demographic data) may be used or disclosed by us in one or more of the following respects:
* To other health care providers (i.e., your general dentist, oral surgeon, etc) in connection with our rendering orthodontic treatment to you (i.e., to determine the results of cleanings, surgery, etc.);
* To third party payors or spouses (i.e., insurance companies, employers with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of your account (i.e., to determine benefits, dates of payment, etc.)
* Internally, to all staff members who have any role in your treatment;
* To your family and close friends involved in your treatment; and/or, any other uses or disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke.
Under the new privacy rules, you have the right to:
* Request restrictions on the use and disclosure of your protected health information;
* Request confidential communication of your protected health information;
* Inspect and obtain copies of your protected health information through us;
* Amend or modify your protected health information in certain circumstances;
* Receive an accounting of certain disclosures made by us of your protected health information; and,
* You may, without risk of retaliation, file a complaint as to any violation by us of your privacy rights with us (by submitting inquiries to our Privacy Contact Person at our office address) or the United States Secretary of Health and Human Services (which must be filled with in 180 days of the violation)
We have the following duties under the privacy rules:
* By law, to maintain the privacy of protected health information and to provide you with this notice setting fourth our legal duties and privacy practices with respect to such information;
* To abide by the terms of our Privacy Notice that is currently in affect;
* To advise you of our right to change the terms of this Privacy notice and to make the new notice provisions effective for all protected health information maintained by us, and that if we do so, we will provide you with a copy of the revised Privacy notice
Please note that we are not obligated to:
* Provide an atmosphere that is totally free of the possibility that your protected health information may be incidentally overheard by other patients and third parties.
By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.