This notice describes how your health information may be used and disclosed and how you may access this information. Please review it carefully.
We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect 10/1/2013 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 the applicable laws, and to make new notice provisions effective for all the protected health information we maintain. When we make a significant change to our privacy practices, we will change this notice and post the new notice clearly and prominently at our practice location. We will also provide copies of the new notice 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.
We may use or disclose your health information for different purposes, including treatment, payment, and healthcare operations. For each of these categories, we have provided a description and an example. Some information, such as HIV-related information, genetic information, alcohol and/or substance abuse records, and mental health records may be entitled to special confidentiality protections under the applicable state or federal law. We will abide by these special protections as they pertain to cases that involve these types of records.
Treatment. We may use or disclose your health information for your treatment. For example, we may disclose your health information to a specialist who is providing you with treatment.
Payment. We may use and disclose your health information to obtain reimbursement for the treatment or services you received from us or another entity involved with your care. Payment activities include billing, collections, claims management, and determinations of eligibility or coverage to obtain payment from you, an insurance company, or another third party. For example, we may send claims to your dental insurance plan containing certain health information.
Healthcare Operations. We may use or disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, training programs, and licensing activities.
Individuals Involved in Your Care or Payment for Your Care. We may disclose your health information to your family, friends, or any other individual identified by you to be involved in your care or in the payment for your care. In addition, we may disclose information about you to a patient representative. If a person has the authority by law to make healthcare decisions for you, we will treat that patient representative in the same manner we would treat you with respect to your health information.
Disaster Relief. We may use or disclose your health information to assist in disaster relief efforts.
Required by Law. We may use or disclose your health information when we are required to do so by law.
Public Health Activities. We may disclose your health information for public health activities, including disclosures to:
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 any correctional institutions or law enforcement officials having lawful custody of the protected health information of an inmate or patient.
Secretary of HHS. We will disclose your health information to the Secretary of the U.S. Department of Health and Human Services when required to investigate or determine compliance with HIPAA.
Worker’s Compensation. We may disclose your PHI to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law.
Law Enforcement. We may disclose your PHI for law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order.
Health Oversight Activities. We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and credentialing and may occur as necessary for licensure and for the government to monitor the healthcare system, government programs, and compliance with civil rights laws.
Judicial and Administrative Proceedings. If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process instituted by someone else involved in the dispute. However, this will only occur if efforts have been made, either by the requesting party or by us, to inform you of the request or to obtain an order protecting the information requested.
Research. We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information.
Coroners, Medical Examiners, and Funeral Directors. We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine the cause of death. We may also disclose PHI to funeral directors consistent with the applicable law to enable them to carry out their duties.
Fundraising. We may contact you to provide you with information about our sponsored activities, including fundraising programs, as permitted by the applicable law. If you do not wish to receive such information from us, you may opt out of receiving these communications.
Your authorization is required, with a few exceptions, for the disclosure of psychotherapy notes, the use or disclosure of PHI for marketing, and for the sale of PHI. We will also obtain your written authorization before using or disclosing your PHI for purposes other than those provided for in this notice (or as otherwise permitted or required by law). You may revoke an authorization in writing at any time. Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization.
Your Health Information Rights
Access. You have the right to view or receive copies of your health information, with limited exceptions. You must make the request in writing. You may obtain a form to request access by using the contact information listed at the end of this notice. You may also request access by sending us a letter to the address at the end of this notice. If you request information that we maintain on paper, we may provide photocopies. If you request information that we maintain electronically, you have the right to an electronic copy. We will use the form and format you request if it is readily producible. We will charge you a reasonable cost-based fee for the cost of the supplies, the labor of copying, and for postage, if you wish to have the copies mailed to you. Contact us using the information listed at the end of this notice for an explanation of our fee structure.
If you are denied a request for access, you have the right to have the denial reviewed in accordance with the requirements of any applicable law.
Disclosure Accounting. With the exception of certain disclosures, you have the right to receive an accounting of disclosures of your health information in accordance with the applicable laws and regulations. To request an accounting of disclosures of your health information, you must submit your request in writing to the Privacy Official. 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 the additional requests.
Right to Request a Restriction. You have the right to request additional restrictions on our use or disclosure of your PHI by submitting a written request to the Privacy Official. Your written request must include (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both; and (3) to whom you want the limits to apply. We are not required to agree to your request except in any case where the disclosure is to a health plan for the purposes of carrying out payment or healthcare operations and the information pertains solely to a healthcare item or service for which you, or a person on your behalf (other than the health plan), has paid our practice in full.
Alternative Communication. You have the right to request that we communicate with you about your health information through an alternative means or at an alternative location. You must make your request in writing. Your request must specify the alternative means or location and provide satisfactory explanation of how payments will be handled under the alternative means or location requested. We will accommodate all reasonable requests. However, if we are unable to contact you using the means or location you have requested, we may contact you using the information we have.
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. If we agree to your request, we will amend your record(s) and notify you of such. If we deny your request for an amendment, we will provide you with a written explanation of why we denied it and explain your rights.
Right to Notification of a Breach. You will receive notifications of breaches of your unsecured protected health information as required by law.
Electronic Notice. You may receive a paper copy of this notice upon request, even if you have agreed to receive this notice electronically on our website or by electronic mail (e-mail).
If you would like 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 if you disagree with a decision we have made regarding access to your health information, in response to a request you have made to amend or restrict the use or disclosure of your health information, or communication using an alternative means or at an alternative location, you may contact us using the 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. 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 privacy regarding 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.
Our Privacy Official: Dr. Vivian Broadway
Telephone: 415 388 6025
Fax: 415 388 1431
Address: 25 Evergreen Avenue, Suite No. 1 | Mill Valley, CA 94941
E-mail: smile@broadwaydds.com
