Blacker Family Dental Takes Patient Privacy Seriously
PLEASE CAREFULLY REVIEW THE FOLLOWING INFORMATION, WHICH EXPLAINS HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED, AS WELL AS HOW YOU CAN GAIN ACCESS TO IT. YOUR PRIVACY IS OF THE UTMOST IMPORTANCE TO US.
Applicable state and federal laws require that we maintain the privacy of your protected health information. We are required to issue this notice concerning our privacy practices and legal duties, and your rights regarding your protected health information. This notice is in effect as of April 14, 2003, and is binding until it is replaced.
We reserve the right to alter the terms of this notice and our privacy practices in accordance with applicable law at any time. We also reserve the right to make any changes in our privacy practices and the terms of this notice effective for all protected health information we possess, including medical information created or received prior to the changes.
You are entitled to receive a copy of our notice upon request. To learn more about our privacy practices or obtain additional copies of this notice, please contact us using the information included at the bottom of this notice.
How We Use or Disclose Your Health Information
Your protected health information will be utilized and disclosed for your treatment, payment, and health care operations. The following are examples of ways in which your protected health care information may be used or disclosed. This list is not exhaustive, but rather demonstrates the types of uses and disclosures that may occur.
Treatment: Your protected health information may be used to provide, manage, or coordinate your healthcare and related services, and may be shared with a third party for this purpose. For example, if you are under the care of another physician (such as one to whom you have been referred) or a home health agency, we may disclose your protected health information as needed in order to ensure they have the necessary information for your diagnosis, treatment, or care. We may also disclose your information to another physician or health care provider (e.g. a laboratory or specialist) who becomes involved in your care at the request of your physician.
Payment: Your protected health information may be used to acquire payment for your health care services. This can include actions taken by your insurer to determine insurance benefits eligibility or coverage, review services you have received for protected health necessity, and undertake utilization review activities. For example, being approved for a hospital stay may require the disclosure of your protected health information to your health plan prior to hospital admission.
Health Care Operations: We may use or disclose your protected health information for certain business and operational activities, including but not limited to student training, employee review, quality assessment, licensing, and other activities. We may also share your protected health information with our third-party business associates, who perform activities such as billing and transcription services. Our business associates sign a written contract containing terms protecting your privacy.
Use and Disclosures Based on Your Written Authorization: Your authorization will be required for all other uses and disclosures of your protected health information, unless otherwise permitted or required by law as described below. You may provide written authorization to use your protected health information, or to disclose it to any party, for any reason. This authorization may be revoked at any time, but a revocation will not affect use or disclosures permitted while the authorization was in effect.
Others Involved in Your Health Care: We may disclose to a relative, friend, or other person identified by you any of your protected health information that is directly related to that person’s involvement in your care. If you are unable to consent or object to a disclosure, we may do so if, based on our professional judgment, we deem it in your best interest. We may also use or disclose protected health information to notify or assist in notifying a family member, personal representative, or other person responsible for your care of your condition, location, or death.
Marketing: Your protected health information may be used for marketing activities such as providing information about treatment alternatives in which you may be interested. For this purpose, we may disclose your information to a business associate. You may opt out of receiving this information (unless it is included in a general newsletter or presented in-person, or is for products or services of nominal value) by using the contact information at the bottom of this notice.
Research, Death, Organ Donation: Your protected health information may be used for research purposes in limited circumstances. As needed, we may disclose your information to a coroner, protected health examiner, organ procurement organization, or funeral director.
Public Health and Safety: We may disclose your protected health information as needed to mitigate a serious and imminent threat to your safety or health, or to the safety and health of others. We may also disclose your information to an authorized government agency overseeing the health care system or government programs (and its contractors), as well as to public health authorities.
Health Oversight: Your information may be disclosed to a health oversight agency for lawful activities such as inspections, audits, and investigations. Government agencies seeking this information may include those overseeing the health care system, benefit programs, and other regulatory programs and civil rights laws.
Abuse or Neglect: We may disclose your protected health information to an appropriate public health authority if there is evidence of child abuse or neglect, or if we suspect that you have been a victim of neglect, abuse, or domestic violence. All such disclosures will be made in accordance with the requirements of applicable state and federal laws.
Food and Drug Administration: We may disclose your protected health information to an individual or company required by the Food and Drug Administration to report product defects or problems, adverse events, or biological product deviations. We may also disclose your information to companies required by the FDA to track products, initiate recalls, make replacements of repairs, or conduct marketing surveillance.
Criminal Activity: We may use or disclose your protected health information if this is required to lessen or prevent a series and imminent threat to the health and safety of a person or the public. Information may also be disclosed to law enforcement if it is required to identify or apprehend an individual.
Required by Law: Your protected health information may be used or disclosed when required by law. For example, to determine whether we are in compliance with federal privacy laws, we must disclose your information to the U.S. Department of Health and Human Services upon request. We may also disclose your information if authorized to do so by workers’ compensation or similar laws.
Process and Proceedings: We may disclose information as necessary when issued a subpoena, administrative order, discovery request, or other request as part of a lawful process. We may also disclose your information to law enforcement officials if presented with a warrant, court order, or grand jury subpoena.
Law Enforcement: Limited protected health information concerning a suspect, crime victim, material witness, missing person, fugitive, person who has admitted to participation in a crime, or person who has escaped from lawful custody may be provided to a law enforcement official. If necessary, we may provide information to a law enforcement official or correctional institution concerning an inmate or other person in lawful custody.
Your Rights as a Patient
Access: You are entitled to view or obtain copies of your protected health information with limited exceptions. Your request for access to this information must be submitted in writing to the contact person listed at the end of this notice. Patients requesting copies will incur a charge of $25.00, or $10.00 per hour to locate your information, as well as the cost of postage if you request a mailed copy. We can also prepare a summary or explanation of your protected health information for a reasonable fee. Contact us for a detailed explanation of our fee structure.
Accounting of Disclosures: You are entitled to receive a list of instances in which your protected health information has been disclosed after April 14, 2003 for purposes other than payment, treatment, healthcare operations, and certain other activities. You will be provided with information concerning the date of the disclosure, the name or entity to whom it was disclosed, a description of the information disclosed, and other relevant information. You may be charged a cost-based fee if you request this information more than once in a 12-month period.
Restriction Requests: You are entitled to request additional restrictions on our use or disclosure of your protected health information. We are not legally bound to requested restrictions but will adhere to them if we agree to your request, except in cases of an emergency. Agreements to additional restrictions must be documented in writing and signed by a party authorized to make the agreement on our behalf.
Confidential Communication: You are entitled to request alternative means of confidential communication about your protected health information, as well as to request an alternative meeting location. We are obligated to accommodate reasonable requests that specify the alternative mode of communication or location and allow us to continue to bill and collect payment. Alternative communication and location requests must be issued in writing.
Amendment: You are entitled to request an amendment to your protected health information. Your request must explain the reason for the amendment. If your request is denied, you will receive a written explanation. You may respond to denied requests with a statement of disagreement, which will be appended to the information you want amended. Upon accepting an amendment request, we will make a reasonable effort to inform other parties, including any parties named by you, of the amendment and to include changes in all future disclosures of the information. Amendment requests must be issued in writing.
Electronic Notice: You are entitled to receive this notice in written form upon request. To obtain a written copy, contact us using the information at the end of this notice.
Questions and Feedback
For more information about our privacy practices, or to address any other questions or concerns, please contact us at the number or address below. We also welcome you to contact us if you suspect that we have violated your privacy rights, disagree with a particular use or disclosure of your protected health information, or disagree with a decision we have made regarding a request. If you would like to submit a written complaint to the U.S. Department of Health and Human Services, we can provide you with the address upon request.
We support your right to privacy concerning your protected health information and take seriously all complaints filed with our office and the U.S. Department of Health and Human Services. This being the case, we would never retaliate again a patient who has filed a complaint.
Blacker Family Dental in Kansas City:
11208 Quincy Ave Kansas City, Missouri 64137
Phone: (816) 763-8400