THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAYBE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
If you have any questions about this notice, please contact us at (607) 273-0327.
We are required by law to:
- Maintain the privacy of protected health information
- Give you this notice of our legal duties and privacy practices regarding health information about you
- Follow the terms of our notice that is currently in effect
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION:
The following describes the ways we may use and disclose health information that identifies you (Health Information). Except for the purposes described below, we will use and disclose health information only with your written permission. You may revoke such permission at any time by writing to our practice Privacy Officer.
For Treatment- We may use and disclose health information for your treatment and to provide you with treatment related health care services. For example, we may disclose health information to doctors, nurses, technicians, or other personnel, including people outside our office who are involved in your medical care and need the information to provide you with medical care.
For Payment- We may use and disclose health information so that we or others may bill and receive payment from you and insurance company’s or a third party for the treatment and services you received. For example, we may give your health plan information about you so they will pay for your treatment.
For Health Care Operations- We may use and disclose health information for health care operations purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and to operate and manage our office. For example, we may use and disclose information to make sure the obstetrical or gynecological care you receive is the highest quality. We also may share information with other entities that have a relationship with you (for example, your health plan) for their health care operation activities. Health information may be disclosed to you to remind you that you have an appointment with us. We also may use and disclose health information to tell you about treatment alternatives or health-related benefits and services that may be of interest to you.
Individuals involved in your care or payment for your care- When appropriate, we may share health information with a person who is involved in your medical care or payment for your care, such as your family or close friend. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.
Research- Under certain circumstances, we may use and disclose health information for research. For example, a research project may involve comparing the health of patients who received one treatment to those who received special approval process. Even without special approval, we may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes, as long as they do not remove or take a copy of any health information.
As Required by Law- We will disclose health information when required to do so by international, federal, state or local law.
To Avert a Serious Threat to Health or Safety- We may use and disclose health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may be able to help prevent the threat.
Business Associates- We may disclose health information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated to protect the privacy of your information and are not permitted to use or disclose any information other than as specified in our contract.
Organ and Tissue Donation- If you are an organ donor, we may use or release health information to organizations that handle organ procurement or other entities engaged in procurement, banking or transportation of organs, eyes or tissues to facilitate organ, eye or tissue donation and transplantation.
Military and Veterans- If you are a member of the armed forces, we may release health information as required by military command authorities. We also may release health information to the appropriate foreign military authority if you are a member of foreign military.
Worker’s Compensation- We may disclose health information for Worker’s Compensation or similar programs. These programs provide benefits for work-related injuries or illness.
Public Health Risks- We may disclose health information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when authorized by law.
Health Oversight Activities- We may disclose health information to a health oversight agency for activities authorized by law. These oversight activities include for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs and compliance with civil rights laws.
YOUR WRITTEN AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES:
The following uses and disclosures of your protected health information will be made only with your written authorization:
- Uses and disclosures of protected health information for marketing purposes
- Disclosures that constitute a sale of your protected health information
Other uses and disclosures of protected health information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you do give us an authorization you may revoke it at any time by submitting a written revocation to our privacy officer and we will no longer disclose protected health information under the authorization, but disclosure that we made in reliance on your authorization before you revoked it will not be affected by the revocation.
You have the following rights regarding health information we have about you:
Right to Inspect and Copy- You have a right to inspect and copy health information that may be used to make decisions about your care or payment for your care. This includes medical and billing records other than psychotherapy notes. To inspect and copy this health information you must make your request in writing to Ithaca Oral Surgery and Implant Center/Dr. Scott Noren at the business address listed on this form. We have up to 30 days to make your protected health information available to you and we may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request. We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state or federal needs based benefit program. We may deny your request in certain limited circumstances. If we do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request and we will comply with the outcome of the review.
Right to an Electronic Copy of Electronic Medical Records- If your protected health information is maintained in an electronic format (known as electronic medical record or electronic health record); you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity. We will make every effort to provide access to your protected health information in the form or format you request, if it is readily producible in such form or format. If the protected health information is not readily producible in the form or format you request your record will be provided in either our standard electronic format or if you do not want this form or format, a readable hard copy form. We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.
Right to Get Notice of a Breach- You have the right to be notified upon a breach of any of your unsecured protected health information.
Right to Amend- If you feel that health information we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our office. To request an amendment, you must make your requesting writing to Ithaca Oral Surgery and Implant Center/ Dr. Scott Noren to the address listed in this form.
Right to an Accounting of Disclosures- You have the right to request a list of certain disclosures we made of health information for purposes other than treatment, payment and health care operations or for which you provided written authorization. To request an accounting of disclosures you must make your request in writing to Ithaca Oral Surgery and Implant Center/ Dr. Scott Noren at the address on this form.
Data Breach Notification Purposes- We may use or disclose your protected health information to provide legally required notices of unauthorized access to or disclose your health information.
Lawsuits and Disputes- If you are involved in a lawsuit or a dispute we may disclose health information in response to a court or administrative order. We also may disclose health information in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute. This is only if efforts have been made to tell you about the requestor to obtain an order protecting the information requested.
Law Enforcement- We may release health information if asked by law enforcement official if the information is: in response to a court order, subpoena, warrant, summons or similar process; limited information to identify or locate a suspect, fugitive, material witness, or missing person; about the victim of a crime even if under certain very limited circumstances we are unable to obtain the persons agreement; about the death we believe may be the result of criminal conduct; about criminal conduct on our premises; and in an emergency to report a crime, the location of the crime or victims, or the identity, description or location the person who committed the crime.
Coroners, Medical Examiners and Funeral Directors- We may release health information to a coroner or medical examiner. This may be necessary for example to identify a deceased person or determine the cause of death. We also may release health information to funeral directors as necessary for their duties.
National Security and Intelligence Activities- We may release health information to authorized federal officials for intelligence, counter intelligence and other national security activities authorized by law.
Protective Services for the President and Others- We may disclose health information to authorize federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or to conduct special investigations.
In Mates or Individuals in Custody- If you are an inmate of correctional institution or under the custody of a law enforcement official, we may release health information to the correction institution or law enforcement official. This release would be necessary for the institution to provide you with health care; to protect your health and safety or the health and safety of others; or the safety and security of the correctional institution.
USES AND DISCLOSURES THAT REQUIRE US TO GIVE YOU AN OPPORTUNITY TO OBJECT AND OPT
Individuals Involved in Your Care or Payment for your Care- Unless you object, we may disclose to a member of your family, a relative a close friend or any other person you identify, your protected health information that directly relates to that persons involvement n your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment.
Disaster Relief- We may disclose your protected health information to disaster relief organizations that seek your protected health information to coordinate your care, or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can do so.
Right to Request Restrictions- You have the right to request restriction or limitation on the health information we use to disclose for treatment, payment or health care operations. You also have the right to request a limit on the health information we disclose to someone involved in your care or the payment for your care (family member or friend). For example you could ask that we not share information about a particular diagnosis or treatment with your spouse. To request a restriction you must make your request in writing to Ithaca Oral Surgery and Implant Center/ Dr. Noren at the address listed in this form. We are not required to agree to your request unless you are asking us to restrict the use and disclosure of your protected health information to a health plan for payment or health care operation purposes and such information to wish to restrict pertains solely to a health care item or service for which you have paid us “out of pocket” for in full. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
Out of Pocket Payments- If you paid out of pocket (you have requested that we not bill your health plan) in full for a specific item or service, you have the right to ask that your protected health information with respect to that item or service not be disclosed to a health plan for purposes of payment or health care operations and we will honor that request.
Right to Request Confidential Communications- You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example you can ask that we only contact you by mail or at work. To request confidential communications you must make your request in writing to Ithaca Oral Surgery and Implant Center/ Dr. Scott Noren to the address listed in this form. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests.
Right to a Paper Copy of this Notice- You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our website as well. www.ithacaimplants.com. To obtain a paper copy of this notice you may ask our front desk staff.
CHANGES TO THIS NOTICE:
We reserve the right to change this notice and make the new notice apply to health information we already have as well as any information we receive in the future. We will post a copy of our current notice at our office. The notice will contain the effective date on the first page in the top right hand corner.
If you believe your privacy right have been violated you may file a complaint with our office or the secretary of the department of health and human services. To file a complaint with our office please contact the front desk staff. All complaints must be made in writing. You will not be penalized for filing a complaint. For routine questions you may ask front desk staff; if they cannot answer your question Dr. Scott Noren will attempt to resolve your concern.
This notice can be given to you in either writing or electronically and you understand this form in English. If you need translation into another language the office will provide a translated version for you.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICE AND CONSENT TO USE AND DISCLOSURE FOR TREATMENT, PAYMENT AND OPERATIONS PURPOSES
By signing below, I hereby acknowledge that I have been provided the opportunity to obtain a copy of this office’s Notice of Privacy Practices and have therefore been advised of how my protected health information may be used and disclosed by the office and how I may obtain access to and control this information. It is posted in the waiting room and available for copy on request. In addition, by signing below, I hereby consent to the use and disclosure of my health information for treatment purposes, payment activities and healthcare operations of the office. I understand that I may refuse to sign this authorization. Treatment, payment, enrollment in a health plan or eligibility for benefits will not be conditioned on signing an authorization if to do so would be prohibited by federal and state law. I may revoke authorization in writing at any time. If I do, it will not affect any previous actions already taken in reliance upon my authorization. I may revoke this authorization by writing a letter and mailing it by certified mail, return receipt requested to the Privacy Officer at the health care provider listed above.
Once health information is disclosed pursuant to this authorization to insurance or other health care entities such as your physician, it is still protected by us but is under their privacy agreements with you separately.
Electronic Disclosure, Electronic Signature and Electronic Statements Agreement
Please read this Electronic Records Disclosure and Agreement carefully:
By checking the boxes on the website for patient forms, AND, by typing your name in the e-sign box here, you consent to the electronic delivery of the disclosures, information you provided, terms and conditions and any other documents to be included in your electronic and paper copy records. You also agree that we do not need to provide you with additional paper (non-electronic) copies of the disclosures, agreements, change notices, terms and conditions and any other documents, unless specifically requested. Once you consent to the disclosures and inclusion of your HIPAA protected information to be included in your records, you may request paper copies, which may result in a small copying fee.