HIPPA & Privacy Statement
NOTICE OF PRIVACY PRACTICES
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
This Notice is solely for your information. WILLIAM U. MOORE, D.D.S., PLLC (We” or “Us”) understands that your personal health information (“Personal Health Information”) is confidential. This Notice of our privacy practiced describes generally how We may use and disclose this Personal Health Information to provide services to you and other purposes that are permitted or required by law. This Notice becomes effective on June 5, 2012. Personal Health Information is protected health information that individually identifies you and relates to past, present, and future health care or payment for such health care services.
We are required by the federal privacy regulations to keep Personal Health Information about you private; give you this Notice of our legal duties and privacy practices with respect to your Personal Health Information; and follow the terms of the Notice that are currently in effect.
HOW WE MAY USE AND DISCLOSE PERSONAL HEALTH INFORMATION
In performing our duties, We may use and disclose your Personal Health Information in various ways. We have provided you with examples in certain categories, however, not every use or disclosure in a category will be listed. Such uses and disclosures include:
We may use or disclose Personal Health Information to your providers, including, physicians who participate in the provision or your health care. We may confirm your prescription with the physician or nursing facility.
When you use your health care benefits, We may use and disclose Personal Health Information about you in several ways, such as, to determine your eligibility in a health care plan, determine your plan benefits, bill and collect payment, coordinate you benefits, or investigate a claim. We may send a claim to your health plan identifying you and services provided to you so that We may be paid.
HEALTH CARE OPERATIONS
We may use and disclose Personal Health Information about you for certain operational, administrative, research and quality assurance activities. For example, We may perform quality of care reviews, investigation of fraud, and review services and products to evaluate our performance in serving you. We may assist your health plan in conducting a review of claims submitted by Us to ensure you are charged correctly. We may contact you for customer surveys to monitor quality of services and products.
PERSONS INVOLVED IN CARE
We may use our discretion to disclose Personal Health Information to notify a family member, your personal representative or another person involved in your care. For example, We may allow a person to pick up your prescription or medical supplies. We may disclose your Personal Health Information to a family member, friend, or other person to the extent necessary to help with your care or with payment for your care.
ADDITIONAL USES OR DISCLOSURES
We may disclose Personal Health Information about you concerning:
- Public health or Safety to address situations as permitted by law, including reporting problems with products or product recall Notices, threats to public health and safety, disaster relief efforts or national security.
- Military as required by military command authorities if you are serving in the military.
- Organ and Tissue Donation to assist in organ or tissue donation and transplantation.
- Law Enforcement to respond to a law enforcement official, court or administrative order or other lawful purposes.
- Coroners, Medical Examiners.
- Regulatory or Administrative Oversight to state insurance department, Office of Civil Rights, Department of Health and Human Services and others that regulate us, contractors who are our business associates and provide services to us who will be required to protect your Personal Health Information.
DISCLOSURE AS YOU REQUEST
We may only use and disclose Personal Health Information as generally described in this Notice or according to laws that apply to Us. Other uses or disclosure of your Personal Health Information will be made only with your written permission, identified as an authorization.
If you provide Us with an authorization, you may revoke that permission at any time by sending a written request to:WILLIAM U. MOORE, D.D.S., PLLC 6232 Peters Creek Road Roanoke, Virginia 24019
If you revoke your permission, We will no longer use or disclose Personal Health Information about you for the reasons stated in your authorization, except to the extent that We have already taken action in reliance on the authorization.
YOUR RIGHTS REGARDING PERSONAL HEALTH INFORMATION
You have the following rights regarding your Personal Health Information:
RIGHT TO INSPECT AND COPY.
You have the right to inspect and copy Personal Health Information that We maintain. If you request a copy of the information, We may charge a fee for the costs of copying, mailing or other supplies associated with you request.
RIGHT TO AMEND.
If you feel that Personal Health Information We have about you is incorrect or incomplete, you may ask Us to amend your Personal Health Information. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request, the current information is accurate and complete or if We did not create the information. If We deny your request, you may send us a written notice of disagreement with our denial.
RIGHT TO ACCOUNTING OF DISCLOSURES.
You have the right to request a list of our disclosures for purposes other than treatment, payment or health care operations or disclosures made to you or your representative, authorized by you or made to law enforcement personnel. Your request must state a time period and may not include dates before April 14, 2003. If you request more than one list in a year, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may change your request at that time before and costs are incurred.
RIGHT TO REQUEST RESTRICTIONS.
You have the right to request that We restrict the way We use or disclose Personal Health Information regarding the treatment, payment or health care operations. You also have the right to request that We restrict the Personal Health Information We disclose about you to someone who is involved in your care or the payment for you care, like a family member or friend. We are not required to agree to your request.
RIGHT TO REQUEST CONFIDENTIAL COMMUNICATIONS.
You have the right to make a reasonable request that we communicate Personal Health Information to you in a certain way or at a certain address. Your request must specify how or where you wish to be contacted. We will comply with reasonable requests.
If you believe your privacy rights have been violated, you may file a complaint with Dr. William Moore General Dentistry
Submit all complaints in writing to:WILLIAM U. MOORE, D.D.S., PLLC 6232 Peters Creek Road Roanoke, Virginia 24019
You must include your name, address, telephone number, the location and a description of the Complaint and We will respond. You may also contact the Secretary of the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint.
CHANGES TO THIS NOTICE
We may change the terms of this Notice and our privacy policies. If We make such changes, the new terms and policies will apply to all Personal Health Information that We currently have or receive in the future. The effective date of this Notice and any revised Notice may be requested via mail.
If you have any questions regarding this Notice, please contact Dr. William Moore General Dentistry at:WILLIAM U. MOORE, D.D.S., PLLC 6232 Peters Creek Road Roanoke, Virginia 24019 (540) 362-3846