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Notice of Privacy Practices for Protected Health Information

This notice describes how your personal health information may be used and disclosed and how you can get access to this information. Please review it carefully.

Maple Street Family Dentistry respects your privacy. We understand that your personal health information is very sensitive. We will not disclose your information to others unless you tell us to do so, or unless the law authorizes or requires us to do so.

With your consent, the practice is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing services to you. Such information may include documenting your symptoms, examination and test results, diagnosis, treatment, and applying for future care or treatment. It also includes billing documents for those services. State law requires us to get your authorization to disclose this information for payment purposes.

Example of use of your health information for treatment purposes

The hygienist or assistant obtains treatment information about you and records it in a health record. During the course of your treatment, the doctor determines a need to consult with another specialist in the area. The doctor will share the information with such specialist and obtain input.

Example of use of your health information for payment purposes

We submit a request for payment to your health insurance company. The health insurance company may request information from us regarding medical care given. It may include your diagnoses, procedure performed, or recommended care.

Example of use of your health information for health care operations

We use your medical records to assess quality and improve services. We may use and disclose medical records to review the qualifications and performance of our health care providers and for training programs. We may contact you to remind you about appointments and give you information about treatment, alternatives, or other health care related benefits or services. We may use and disclose your information to conduct or arrange for services, including medical quality reviews by your health plan; accounting, legal, risk management, and insurance services; audit functions, including fraud and abuse detection and compliance programs.

Your Health Information Rights

The health and billing records we maintain are the physical property of the practice. The information in it, however, belongs to you. You have a right to the following:

• Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office. We are not required to grant the request but will comply with any request granted.
• Obtain a paper copy of this Notice of Privacy Practices for Protected Health Information (“Notice”) by making a request at our office.
• Request that you be allowed to inspect and copy your health record and billing record. You may exercise this right by delivering the request in writing to our office. We have a form available for this type of request.
• Have us review a denial of access to your health information except in certain circumstances.
• Ask us to change your health information. You may give this request in writing. You may write a statement of disagreement if your request is denied. It will be stored in your medical record and included with any release of you records.
• When you request, we will give a list of disclosures of your health information. The list will not include disclosures to third party payers. You may receive this information without charge once every 12 months. We will notify you of the cost involved if you request this information more than once in 12 months.
• Ask that your health information be given to you by another means or another location. Please sign, date, and give us request in writing.
• Cancel prior authorizations to use or disclose health information by giving us a written revocation. Your revocation does not affect information that has already been released. It also does not affect any action taken before we have it. Sometimes, you cannot cancel an authorization if its purpose was to obtain insurance.

For help with these rights during normal business hours, please contact Roxie Couch, Privacy Officer, at 509-891-5001 Ext. 14.

Our Responsibilities

The practice is required to do the following:

• Maintain the privacy of your health information as required by law.
• Provide you with a notice of our duties and privacy practices as to the information we collect and maintain about you.
• Abide by the terms of this notice.
• Notify you if we cannot accommodate a requested restriction or request.
• Accommodate your reasonable requests regarding methods to communicate health information to you.
• We reserve the right to amend, change, or eliminate provisions in our privacy practices. To access practices and to enact new provisions regarding the protected 3 health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy or by visiting our office and picking up a copy.

To Request Information or File a Complaint

If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact the Privacy Officer.

Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to the Privacy Officer. You may also file a complaint by mail to the U.S. Secretary of Health and Human Services.

We respect your right to file a complaint with us or with the U.S. Secretary of Health and Human Services. If you complain, we will not retaliate against you.

Other Disclosures and Uses

Notification

Unless you object, we may release health information about you to a friend or family member who is involved in your medical care. We may also give information to someone who helps pay for your care. We may tell your family or friends your condition and that you are in a hospital. In addition, we may disclose health information about you in an emergency.

Use and Disclosure without Your Authorization

We may use and disclose your protected health information without your authorization as follows:

• With Medical Researchers – If the research has been approved and has policies to protect the privacy of your health information. We may also share information with medical researchers preparing to conduct a research project.
• To Funeral Directors/Coroners – Consistent with applicable law to allow them to carry out their duties.
• To Organ Procurement Organizations (tissue donation and transplant) – Persons who obtain, store, or transplant organs.
• To the Food and Drug Administration (FDA) – Relating to adverse events with products and product defects or post marketing surveillance to enable product recalls, repairs, or replacements.
• Workers’ Compensation – We may disclose your personal health information to the extent necessary to comply with laws relating to workers’ compensation.
• Public Health – As required by law, we may disclose your personal health information to public health or legal authorities charged with preventing or controlled disease, injury, or disability.
• Abuse and Neglect – We may report abuse or neglect to public authorities.
• Correctional Institutions – If you are an inmate of a correctional institution, we may disclose to the institution or its agents your personal health information necessary for your health and the health and safety of other individuals.
• Law Enforcement Purposes – When we receive a subpoena, court order, or other legal process, or you are a victim of a crime.
• Health and Safety Oversight Activities – Federal law allows us to release your personal information to appropriate health oversight agencies or for oversight activities.
• Disaster Relief Purposes – We may share health information with disaster relief agencies to assist in notification of your condition to family or others.
• Work-Related Conditions That Could Affect Employee Health – An employer may ask us to assess health risks on a job site.
• Military Authorities of U.S. and Foreign Military Personnel – The law may require us to provide information necessary to a military mission.
• Judicial/Administrative Proceedings – At your request or as directed by a subpoena or court order.
• Specialized Government Functions – We may share information for national security purposes.

Other Uses

Other uses and disclosures besides those identified in this Notice will be made only as allowed or authorized by law or with your written authorization.

Effective Date

04/14/2003