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 PURSUANT TO FEDERAL REGULATIONS.

PLEASE REVIEW IT CAREFULLY.

At Rockford Downtown Dental, we understand that information about you and your health is personal. We are committed to protecting your health care information. We create a record of the care and services you receive directly from our medical staff. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice of Privacy Practices (“Notice”) applies to all of the records of your care generated by our office. This Notice will tell you about the ways in which our office may use and disclose your protected health information (“PHI”). This Notice also describes your rights and certain obligations our office has regarding the use and disclosure of PHI.

REGULATORY REQUIREMENTS. Our office is required by law to maintain the privacy of your PHI, to provide individuals with notice of our office’s legal duties and privacy practices with respect to PHI, and to abide by the terms described in the Notice currently in effect. Information disclosed pursuant to this Notice may be subject to redisclosure by the recipient and may no longer be protected by the HIPAA Privacy Rule.

YOUR RIGHTS. You have the following rights regarding your PHI:

Restrictions. You may request that our office restrict the use and disclosure of your PHI. To request restrictions, you must make your request in writing to our Privacy Officer using the applicable form. In your request, you must tell us (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 restrictions to apply, for example, disclosures to your spouse.

Alternative Communications. You have the right to request that communications of PHI to you from our office be made by particular means or at particular locations. For instance, you might request that communications be made at your work address, instead of your home address. Your requests must be made in writing using our form and sent to the Privacy Officer. We will accommodate your reasonable requests.

Inspect and Copy. Generally, you have the right to inspect and copy your PHI that our office maintains, provided that you make your request in writing to our Privacy Officer. If you request copies of your PHI, we may impose a reasonable fee to cover copying and postage. If we deny access to your PHI, we will explain the basis for denial and your opportunity to have your request and the denial reviewed by a licensed health care professional (who was not involved in the initial denial decision) designated as a reviewing official. If our office does not maintain the PHI you request and if we know where that PHI is located, we will tell you how to redirect your request.

Amendment. If you believe that your PHI maintained by our office is incorrect or incomplete, you may ask us to correct your PHI. Your request must be made in writing, and it must explain why you are requesting an amendment to your PHI. We can deny your request if your request relates to PHI: (i) not created by our office; (ii) not part of the records our office maintains; (iii) not subject to being inspected by you; or (iv) that is accurate and complete. If your request is denied, we will provide you a written denial that explains the reason for the denial and your rights to: (i) file a statement disagreeing with the denial; (ii) if you do not file a statement of disagreement, submit a request that any future disclosures of the relevant PHI be made with a copy of your request and our office’s denial attached; and (iii) complain about the denial.

Accounting of Disclosures. You generally have the right to request and receive a list of the disclosures of your PHI we have made at any time during the six (6) years prior to the date of your request (provided that such a list would not include disclosures made prior to April 14, 2003). This right includes an accounting of disclosures made for treatment, payment, and healthcare operations through an electronic health record during the three years prior to your request. The list will not include disclosures made at your request, with your authorization, and does not include certain uses and disclosures to which this Notice already applies, such as those: (i) for treatment, payment, and health care operations; (ii) made to you; (iii) for our office’s patient list;

(iv) for national security or intelligence purposes; or (v) to law enforcement officials. You should submit any such request to our Privacy Officer. We will provide the list to you at no charge, but if you make more than one request in a year you will be charged a fee of the costs of providing the list.

Right to Copy of Notice. You have the right to receive a paper copy of this notice upon request. To obtain a paper copy of this notice, please contact the Privacy Officer at:

Privacy Officer
Rockford Downtown Dental
112 N Monroe St. Rockford, MI 49341
616-866-4445
Click to email

HOW WE MAY USE AND DISCLOSE MEDICAL INFORMATION ABOUT YOU. Our office may use or disclose your PHI for the purposes described below without obtaining written authorization from you. In addition, our office and the members of its medical and allied health professional staff who participate in the organized health care arrangement described below may share your PHI with each other as necessary to carry out their treatment, payment and health care operations related to the organized health care arrangement. We may also disclose your PHI to certain contractors or other business associates that provide service to our office; these “Business Associates” will be subject to HIPAA and are required to comply with the same restrictions and prohibitions that apply to us.

For Treatment. Our office may use and disclose PHI in the course of providing, coordinating, or managing your medical treatment, including the disclosure of PHI for treatment activities of another health care provider.

For Payment. Our office may use and disclose PHI in order to bill and collect payment for the health care services provided to you. For example, we may need to give PHI to your health plan in order to be reimbursed for the services provided to you. We may also disclose PHI to its business associates, such as billing companies, claims processing companies, and others that assist in processing health claims. We may also disclose PHI to other health care providers and health plans for the payment activities of such providers or health plans.

For Health Care Operations. Our office may use and disclose PHI as part of its operations, including for quality assessment and improvement, such as evaluating the treatment and services you receive and the performance of staff and physicians in caring for you, patient surveys, provider training, underwriting activities, compliance and risk management activities, planning and development, credentialing and peer review activities, and health care fraud and abuse detection or compliance, and management and administration. We may disclose PHI to doctors, nurses, technicians, students, attorneys, consultants, accountants, and others for review and learning purposes, to help make sure our office is complying with all applicable laws, and to help us continue to provide quality health care to its patients.

As Required by Law and Law Enforcement. Our office may use or disclose PHI when required to do so by applicable laws and when ordered to do so in a judicial or administrative proceeding. We may also use or disclose 1 PHI upon a properly documented and limited request from law enforcement agencies.

Special Protections for Substance Use Disorder Records: If our office receive or maintain records protected by federal law relating to substance use disorder (42 CFR Part 2), we will not use or disclose such records in any civil, criminal, administrative, or legislative proceedings against you without your specific written consent or a court order that meets the requirements of the law.

For Public Health Activities and Public Health Risks. Our office may disclose PHI to government officials in charge of collecting information about births and deaths, preventing and controlling disease, or to notify a person who may have been exposed to a communicable disease or may be at risk of contracting or spreading a disease or condition.

For Health Oversight Activities. Our office may disclose PHI to the government for oversight activities authorized by law, such as audits, investigations, inspections, licensure or disciplinary actions, and other proceedings, actions or activities necessary for monitoring the health care system, government programs, and compliance with civil rights laws.

Coroners, Medical Examiners, and Funeral Directors. Our office may disclose PHI to coroners, medical examiners, and funeral directors for the purpose of identifying a decedent, determining a cause of death, or otherwise as necessary to enable these parties to carry out their duties consistent with applicable law.

Research. Under certain circumstances, we may use and disclose PHI for medical research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition.

To Avoid a Serious Threat to Health or Safety. Our office may use and disclose PHI, to law enforcement personnel or other appropriate persons, to prevent or lessen a serious threat to the health or safety of a person or the public.

Specialized Government Functions. Our office may use and disclose PHI of military personnel and veterans under certain circumstances. We may also disclose PHI to authorized federal officials for intelligence, counter intelligence, and other national security activities, and for the provision of protective services to the President or other authorized persons or foreign heads of state or to conduct special investigations.

Disclosures to You or for HIPAA Compliance Investigations. Our office may disclose your PHI to you or to your personal representative, and is required to do so in certain circumstances described below in connection with your rights of access to your PHI and to an accounting of certain disclosures of your PHI. Our office must disclose your PHI to the Secretary of the United States Department of Health and Human Services (the "Secretary") when requested by the Secretary in order to investigate our compliance with privacy regulations issued under the federal Health Insurance Portability and Accountability Act of 1996.

Patient List; Marketing. Unless you object, our office may use some of your PHI to maintain a list of patients it has served. This information may include your name, treatment facility, and the services we provided to you. This patient list and the information on it may be used for marketing purposes. If we intend to use or disclose your substance use disorder records for fundraising or marketing purposes, our office will first provide you with a clear and conspicuous opportunity to elect not to receive any such communications.

Disclosures to Individuals Involved in Your Health Care or Payment for Your Health Care. Unless you object, our office may disclose your PHI to a family member, other relative, friend, or other person you identify as involved in your health care or payment for your health care.

OTHER USES AND DISCLOSURES. Other types of uses and disclosures of your PHI not described above will be made only with your written authorization; you have the right to revoke your authorization in writing. If you revoke your authorization, our office will no longer use or disclose PHI about you for the reasons covered in your written authorization. Please understand that our office is unable to recover any disclosures already made with your authorization, and that we are required to retain records of the care provided to you.

RIGHT TO FILE A COMPLAINT. At our office, we value the relationships we develop with our patients, our patients’ privacy, and the trust our patients’ have in us. As such, we make every effort to remedy any issues or concerns you may have. You may submit any complaint regarding your privacy rights to:

Privacy Officer
Rockford Downtown Dental
112 N Monroe St. Rockford, MI 49341
616-866-4445
Click to email

You also have the right to file a complaint with the Secretary of the Department of Health and Human Services, Office for Civil Rights. You will not be penalized for filing a complaint. You may contact the Office for Civil Rights at:

Office for Civil Rights
U.S. Department of Health and Human Services
233 N. Michigan Ave., Suite 240
Chicago, IL 60601
T: (800) 368-1019
F: (312) 886-1807

The process for filing a complaint regarding the unauthorized use or disclosure of records protected by 42 CFR Part 2 (Substance Use Disorder records) is the same as the process described above for any other privacy complaint.

PLEASE CONTACT THE PRIVACY OFFICER IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE OF PRIVACY PRACTICES OR YOUR PRIVACY RIGHTS.