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OUR LEGAL DUTY
We are required by applicable federal and state law to maintain
the privacy of your health information. We are also required to
give you this Notice about our privacy practices, our legal duties,
and your rights concerning your health information. We must
follow the privacy practices that are described in this Notice while
it is in effect. This Notice takes effect (01/10/2010) and will
remain in effect until we replace it.
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. We
reserve the right to make the changes in our privacy practices and the
new terms of our Notice effective for all health information that we
maintain, including health information we created or received before
we made the changes. Before we make a significant change in our
privacy practices, we will change this Notice and make the new Notice
available upon request.
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 or
on the Contact Us page of this website.
USES AND DISCLOSURES OF HEALTH
INFORMATION
We use and disclose health information about you for
treatment, payment, and healthcare operations. For example:
Treatment: We may use or disclose your health information to a
physician or other healthcare provider providing treatment to you.
Payment: We
may use and disclose your health information to obtain payment for
services we provide you.
Healthcare Operations: We may use and disclose your health
information in connection with our healthcare operations.
Healthcare operations include quality assessment and improvement
activities, reviewing the competence or qualifications of healthcare
professionals, evaluating practitioner and provider performance,
conducting training programs, accreditation, certification licensing
or credentialing activities.
Your Authorization: In addition to our use of your health
information for treatment, payment or healthcare operations, you may
give us written authorization to use your health information or to
disclose it to anyone for any purpose. If you give us an
authorization you may revoke it in writing at any time. Your
revocation will not affect any use or disclosures permitted by your
authorization while it was in effect. Unless you give us a
written authorization, we cannot use or disclose your health
information for any reason except those described in this Notice.
To Your Family and Friends: We must disclose your health
information to you, as described in the Patient Rights section of this
Notice. We may disclose your health information to a family
member, friend or other person to the extent necessary to help with
your healthcare or with payment for your healthcare, but only if you
agree that we may do so.
Persons Involved in Care: We may use or disclose health
information to notify, or assist in the notification of (including
identifying or locating) a family member, your personal representative
or another person responsible for your care, of your location, your
general condition, or death. If you are present, then prior to
use or disclosure of your health information, we will provide you with
an opportunity to object to such uses or disclosures. In the
event of your incapacity or emergency circumstances, we will disclose
health information based on a determination using our
professional judgment disclosing only health information that is
directly relevant to the person's involvement in your healthcare.
We will also use our professional judgment and our experience with
common practice to make reasonable inferences of your best interest in
allowing a person to pick up filled prescriptions, medical supplies,
x-rays, or other similar forms of health information.
Marketing Health-Related Services: We will not use your health
information for marketing communications without your authorization.
Required by Law: We may use or disclose your health information
when we are required to do so by law.
Abuse or Neglect: We may disclose your health information to
appropriate authorities if we reasonably believe that you are a
possible victim of abuse, neglect, or domestic violence or the
possible victim of other crimes. We may disclose your health
information to the extent necessary to avert a serious threat to your
health or safety or the health or safety of others.
National Security: We may disclose to military authorities the
health information of Armed Forces personnel under certain
circumstances. We may disclose to authorized federal officials
health information required for lawful intelligence,
counterintelligence, and other national security activities. We
may disclose to correctional institution or law enforcement officials
having lawful custody of protected health information of inmate or
patient under certain circumstances.
Appointment Reminders: We may use or disclose your health
information to provide you with appointment reminders (such as
voicemail messages, postcards, or letters).
PATIENT RIGHTS
Access: You have the right to look at or get copies of your
health information with limited exceptions. You may request that
we provide copies in a format other than photocopies. We will
use the format that you request unless we cannot practicably do so.
(You must make a request in writing to obtain access to your health
information. You may obtain a form to request access by using
the contact information listed at the end of this Notice or on the
Contact Us page of this website. You may also obtain the form
from the Records Request page of this website. We will charge you a
reasonable cost-based fee for expenses such as copies and staff time.
You may also request access by sending us a letter to the address at
the end of this Notice. If you request copies, we will charge
you $.50 for each page, $30 per hour for staff time to copy your
health information, and postage if you want the copies mailed to you.
If you request an alternative formation, we will charge a cost-based
fee for providing your health information in that format. If you
prefer, we will prepare a summary or an explanation of your health
information for a fee. Contact us using the information listed
at the end of this Notice or on the Contact Us page of our website for
a full explanation of our fee structure.)
Disclosure Accounting: You have the right to receive a
list of instances in which we or our business associates disclosed
your health information for purposes other than treatment, payment,
healthcare operations and certain other activities, for the last 6
years, but not before April 14, 2003. If you request this
accounting more than once in a 12-month period, we may charge you a
reasonable, cost-based fee for responding to these additional
requests.
Alternative Communication: You have the right to request that
we communicate with you about your health information by alternative
means or to alternative locations (You must make your request in
writing) Your request must specify the alternative means or
location, and provide satisfactory explanation how payments will be
handled under the alternative means or location you request.
Amendment: You have the right to request that amend your health
information. (Your request must be in writing, and it must
explain why the information should be amended.) We may deny your
request under certain circumstances.
Electronic Notice: If you receive this Notice on our Website or
by electronic mail (e-mail), you are entitled to receive this Notice
in written form.
Questions and
Complaints
If you want more information
about our privacy practices or have questions or concerns, please
contact us.
If you are concerned that we may have violated your privacy rights, or
you disagree with a decision we made about access to your health
information or in response to a request you made to amend or restrict
the use or disclosure of your health information or to have us
communicate with you by alternative means or at alternative locations,
you may complain to us using the contact information listed at the end
of this Notice or on the Contact Us page of our website. You
also may submit a written complaint to the U.S. Department of Health
and Human Services. We will provide you with the address to file
your complaint with the U.S. Department of Health and Human Services
upon request.
We support your right to the privacy of your health information.
We will not retaliate in any way if you choose to file a complaint
with us or with the U.S. Department of Health and Human Services.
Contact Officer: Amanda Pace
Telephone: (770)834-6663 Fax:
(770)836-5210
E-Mail:
Address: 535 Newnan Street, Carrollton, GA 30117
©2002, 2009 American Dental
Association. All Rights Reserved
Reproductions and use of this form by dentists and their staff is
permitted. Any other use, duplication or distribution of this
form by any other party requires the prior written approval of the
American Dental Association.
This Form is for educational use only, does not constitute legal
advice, and covers only federal, not state law (August 14, 2002; April
30, 2009)
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