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Daniel R.
Burgmeier, D.D.S.,P.C.
-
NOTICE OF PRIVACY
PRACTICES
THIS NOTICE DESCRIBES HOW
HEALTH 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.
~
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 April 14.2003 . 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.
USES AND DISCLOSURES OF
HEALTH INFORMATION
We use and
disclose health information about you for treatment, payment, and health care
operations. For example:
Treatment: We may use or
disclose your health information to a physician or other health care provider
pro- viding treatment to you.
Payment: We may use and
disclose your health information to obtain payment for services we provide to
you.
Health care Operations:
We
may use and disclose your health information in connection with our health care
operations. Health care operations include quality assessment and improvement
activities. reviewing the competence or qualifications of health care
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 health care 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 health care or with payment for your
health care. 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 health care. We will also
use our professional judgment and our experience with common practice to make
reason- able 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 written 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 official having lawful custody of
protected health information of Inmate or patient under certain circum-
stances.
Appointment
Reminders:
We may use or disclose your
health information to provide you with appointment reminders (such as voice mail
messages. postcards. or letters)
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 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 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 $0- for each page. $- per hour for staff time to locate and copy your
health information. and postage if you want the copies mailed to you. If you
request an alternative format. 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 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. health care 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.
Restriction: You have the
right to request that we place
additional restrictions on our use or disclosure of your health information. We
are not required to agree to these additional restrictions. but if we do. we
will abide by our agreement (except in an emergency).
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 we 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 Web site or by electronic mail
(e-mail), you are entitled to receive this Notice in written form.
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. You also may submit a written
complaint to the US. 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:
Shelle R.
Staudt, Office Manager
Telephone 641/423-0064
Fax: 641/421-7544
Address: 2800 4th Street S.W.. Suite 1, Mason City, Iowa 50401
© 2002 American Dental
Association
All Rights Reserved
Reproduction
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 or the
American Dental Association
This
form is educational only. does not constitute legal advice, and covers only
federal. not state, law (August 14. 2002).