WILMETTE DENTAL, LTD., NOTICE OF PRIVACY POLICY
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. The
privacy of your health information is important to us.
We
understand that medical/dental information about you and your health is
personal. We are committed to
protecting your health information. We
create a record of the care and services you receive at our office in order
to provide you with quality care and to comply with certain legal
requirements. Federal and state
law requires us to maintain the privacy of your health information.
That law also requires us 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 we describe in this notice while it is in effect.
This notice takes effect April 14, 2003, and will remain in effect
until we replace it.
USES
AND DISCLOSURES OF HEALTH INFORMATION
We
use and disclose health information about you for treatment, payment, and
health care operations. For
example:
Treatment: We may use your health information for treatment or disclose it to a
dentist, physician or other health care professional providing treatment for
you.
Payment: We may use and disclose your health information to obtain payment for
services we provide you. We may
also disclose your health information to another health care provider or
entity that is subject to the federal Privacy Rules for its payment
activities.
Health Care Operations: We
may use and disclose your health information for our office operations.
These uses and disclosures are necessary to run the office and ensure
that all of our patients receive quality care.
Health care operations include quality assessment and improvement
activities, evaluating practitioner and provider performance, conducting
training programs, accreditation, certification, licensing or credentialing
activities. We may also combine
health information about many office patients to decide what additional
services the office should offer, whether staff should be added, and whether
certain new treatments are effective. We
may also disclose information to dentists, laboratory technicians, and other
office personnel for review and training purposes.
On Authorization: You
may give us written authorization to use your health information or to
disclose it to anyone for any purpose.
If you give us authorization, you may revoke it in writing at any
time. Your revocation will not
affect any uses 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.
Family and Friends:
We may disclose your health information to a family member, friend or other
person to the extent necessary to help with your health care or with payment
for that health care. Such uses
and disclosures will be made only with your permission if you are present,
unless you are incapacitated or there is an emergency circumstance where we
must exercise professional judgment. We
may use professional judgment and 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. Federal law
(HIPAA) provides that the Privacy Rules shall not interfere with effective
patient care.
Appointment Reminders:
We may use and disclose your health information to provide you with
appointment reminders such as telephone calls, answering machine and
voicemail messages, postcards, or letters, unless you opt out in writing.
We may also inform you about treatment options or alternatives or
other health-related benefits and services that may be of interest to you.
Disaster Relief: We
may use and disclose your health information to a public or private entity
authorized by law or by its charter to assist in disaster relief efforts.
Public Benefit: We
may use and disclose your health information as authorized by law for the
following purposes deemed to be in the public interest or benefit:
-
As required by law
-
As authorized by state worker’s compensation laws
-
For public health activities, including disease and vital statistic
reporting, child abuse reporting, FDA oversight, and to employers regarding
work-related illness or injury
-
To report adult abuse, neglect, or domestic violence
-
To health oversight agencies
-
In response to court and administrative orders and other lawful
processes
-
To law enforcement officials pursuant to subpoenas and other lawful
processes, concerning crime victims, suspicious deaths, crimes on our
premises, reporting crimes in emergencies, and for purposes of identifying
or locating a suspect or other person
-
To coroners, medical examiners, and funeral directors
-
To avert a serious threat to health or safety
-
To the military and to federal officials for lawful intelligence,
counterintelligence, and national security activities
-
To correctional institutions regarding inmates
PATIENT
RIGHTS
Access: You have the right to
inspect health information, with limited exceptions.
The request must be made in writing.
You have the right to request copies of your health information, and
may request that we provide copies in a format other than photocopies.
We will use the format requested unless we cannot practicably do so.
We will charge a reasonable cost-based fee that may include labor,
copying costs and postage. If
you request an alternative format, we will charge a cost-based fee for
providing your health information in that format.
Amendment: You have the right to request that our office amend your health
information for as long as our office keeps the information.
The request must be writing, and it must explain why we should amend
the information. We may deny
the request if our office did not create the information, the information is
not part of the health information kept by our office, or the information is
accurate and complete.
Disclosure Accounting:
You have the right to request an “accounting of disclosures.”
This is a list of the disclosures we made of health information, not
related to treatment, payment and health care operations of the office,
which you did not specifically authorize.
Your request must be made in writing to the Privacy Officer, and it
must state a time period, which may not be longer than six years and may not
include dates before April 14, 2003.
Restriction:
You have the right to request in writing additional restrictions or
limitations on our use or disclosure of health information.
We are not required to agree to these additional restrictions, but if
we do, we will comply with the request (except in an emergency).
Any agreement we may make to a request for additional restrictions
must be in writing signed by a person authorized to make such an agreement
on our behalf. The request is
not binding unless our agreement is in writing.
Alternative Communication: You
have the right to request that we communicate with you about health
information by alternative means or to alternative locations.
The request must be made in writing, and it must specify the
alterative means or location. We
will accommodate all reasonable requests.
We
reserve the right to change our privacy practices and the terms of the
privacy notice at any time, provided such applicable law permits the
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 that we created or received before we made the changes, as well
as any information we receive in the future.
Before we make a significant change in our privacy practices, we will
change the notice of privacy practices and make the new notice available
upon request.
QUESTIONS
AND COMPLAINTS
You
are entitled to a paper copy of this notice at any time.
If you want more information about our privacy policy or have
questions or concerns, please contact our privacy officer.
If you believe your privacy rights have been violated, you may file a
complaint in writing with the privacy officer or with the Secretary of the
Department of Health and Human Services.
A complaint form will be provided upon request.
You will not be penalized for filing a complaint.
Dental
Practice:
Wilmette Dental, Ltd.
Dentist:
Peter H. Neuhaus, DDS
Privacy
Officer:
Megan Baker
Address:
344 Linden Avenue, Wilmette, IL
60091
Telephone:
(847) 251-0085
