Northlake
Dental
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.
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 April
14, 2003, and will remain in effect until we replace it.
We reserve the right to change our privacy practices and applicable
law permits the terms of this Notice at any time, provided such
changes. 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 at the end of
this Notice.
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 to 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 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 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 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 by 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
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 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 $0.15 for each page, $10.00 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
additional 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, 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.
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.
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. You may also submit a written complaint
to the U. S. Department of Health and Human Services at 1301 Young
Street, Suite 1169, Dallas, TX 75202 (214-767-4056).
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: Dr.P.Shannon Allison
Telephone: 985-626-3338 Fax: 985-626-0219
Address: 2030 North Causeway Blvd., Mandeville, LA 70471
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