Notice of Privacy Practices (HIPPA compliance)-
This notice describes how medical/dental information about you may be used and disclosed and how you can obtain access to this information. Please review it carefully.
We are required by law to give you this Notice of our duties and privacy practices and your rights. We are required to follow the terms of this Notice. This Notice also describes some, but not all of the uses and disclosures we may make with your protected health information. This Notice also describes your rights to access and control your protected health information including demographic information that may identify you and that relates to your past, present, or future physical or mental health condition and related health care services. There are other laws that provide additional protections for medical information related to treatment for mental health, alcohol abuse, drug abuse, and HIV/AIDS. We will follow the requirements of those laws for these types of medical information.
We May Use and Disclose Information for the Following Purposes
Treatment: We will use or disclose your protected health information to provide treatment, and to coordinate, or manage your healthcare and any related services. For example, we give information to doctors, hygienists, lab technicians, and others, including information from tests you receive and we record that information for others to use. We may provide information to your health plan or other providers to arrange for a referral or consultation.
Payment: We will use or disclose your protected health information, as needed, to obtain payment for your health care services. For example, we may contact your insurer to verify benefits for which you are eligible, obtain prior authorization, and give them details they need about your treatment to make sure they will pay for your care. We will also use or disclose your medical information to bill directly and to obtain payment from third parties that may be responsible for payment, such as family members.
Health Care Operations: We will use or disclose your protected health information, as needed, in order to perform healthcare operations. Healthcare operations include, but are not limited to: quality assessment/improvement activities; risk management, claims management, legal consultation, doctor and employee review activities; licensing; and regulatory surveys. We may also disclose your protected health information to our business associates that perform activities on our behalf, for example, Medicare; and for other business planning activities.
Appointments and Services: We may use and disclose your protected health information to remind you of an appointment, or to give you information about treatment alternatives or other health related benefits or services that may interest you.
Individuals Involved In Your Care/Disaster Relief Organizations We may disclose your protected health information to a friend or family member who is involved in your care unless you ask us not to. We may disclose information to disaster relief organizations, such as the Red Cross, so that your family can be notified about your condition and location.
With Your Authorization: We may use or disclose your protected health information for purposes not described in this Notice, or otherwise permitted by law, only with your written authorization. You may revoke any authorization at any time, in writing, but only as future uses or disclosures, and only where we have not already acted in reliance on your authorization.
Uses and Disclosures We May Make Without Your Authorization, Consent, or Opportunity to Object
Required By Law: We may use or disclose your protected health information to he extent that the use or disclosure is required by law, but only to the extent and under the circumstances provided in such law.
Public Health: We may use or disclose your protected health information for public health activities such as reporting births, deaths, communicable diseases, injury or disability, ensuring the safety of drugs and medical devices, reporting child and sexual abuse, and for work place surveillance or work related illness and injury.
Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.
Abuse, Neglect or Domestic Violence: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of abuse or neglect. In addition, we may disclose your protected health information if we believe you may be a victim of abuse, neglect or domestic violence to the governmental agency or entity authorized to receive such information,. This disclosure will be made consistent with the requirements of applicable federal and state laws.
Food and Drug Administration: We may disclose your protected health information to a person or company required by the Food and Drug Administration to report adverse events; product defects or problems, biologic product deviations, or to track products; to enable product recalls, to make repairs or replacements, or to conduct post marketing surveillance, as required.
Legal Proceedings: We may disclose your protected health information in response to court or administrative orders, or under certain circumstances in response to subpoenas, discovery requests or other lawful processes.
Law Enforcement: We may disclose your protected health information to identify or locate suspects, fugitives or witnesses, or victims of crime, to report deaths from crime, crimes on the premises, or in emergencies, the commission of a crime.
Coroners, Medical Examiners, Funeral Directors: We may disclose your protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose your protected health information to a funeral director in order to permit them to carry out their duties.
Organ Donation: We may disclose your protected health information to organizations that handle organ procurement and/or eye or tissue transplantation.
Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposed and established by protocols to ensure your privacy.
National Security: We may disclose your health information to authorized federal officials for conducting national security and intelligence activities including for the provision of protective services to the President
Criminal Activity: We may disclose your protected health information consistent with applicable federal and state laws if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
Military Activity: We may disclose your protected health information if you are in the armed forces and information is required by command authorities, or for the purposes of a determination by the Department of Veteran Affairs for your eligibility for benefits.
Correction Institutions: We may disclose your protected health information if you are an inmate for your health and the health, and safety of others.
Your Health Information Rights
Right to Obtain a Copy of this Notice of Privacy Practice We will provide you with a copy of the current Notice of Privacy Practices if you request it. A copy of the current Notice in effect will be available at the registration desk and/or at the reception deck. You have the right to obtain a paper copy of this Notice upon request, even if you have agreed to accept this notice electronically.
Right to Request a Restriction on Certain Uses and Disclosures: You have the right to request restrictions on uses and disclosures of your medical/dental information for the purposes of treatment, payment or healthcare operations. We are not required to allow your request. If we do agree with the request, we will comply with your request except to the extent that disclosure has already occurred or if you are in need of emergency treatment and the information is needed t provide the emergency treatment.
Right to Request an Amendment to your Health Record: You may make a written request to amend your protected health information. You must give us a reason for the amendment. In certain case, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement. We will provide you with a copy of any such rebuttal. Please contact our Business Office Manager is you have any questions about amending your health record.
Right to Obtain an Accounting of Disclosures of Your Health Information: The accounting will only provide information about disclosures made for purposes other than treatment, payment or healthcare operations; disclosures to you or authorized by you are excluded. You have the right to receive specific information regarding disclosures made only after April 14, 2003. Please contact our Business Office Manager to obtain an Accounting and disclosure Report.
Contact: To exercise any of the rights described in this Privacy Practices Notice, or if you have any questions about this Notice, please contact our Business Office Manager at (312) 922-9595 or mail questions to: Michigan Avenue Dental Associates, Suite 1212, 122 South Michigan Avenue, Chicago, Illinois 60603, Attention: Business Office Manager. To file a complaint with the Compliance Hotline call 1-866-665-4296. You also have the right to file a complaint with the Secretary of the Department of Health and Human Services, Office of Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue S.W., Room 509F, HHH Building, Washington, D.C. 20201. There will be no retaliation for filing a complaint.
Changes to this Notice: We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for information we already have about you as well as any information we receive in the future. We will post a copy of the current Notice in our facility and it will also be posted on our web site at www.madachicago.com.
