Your Information. Your Rights. Our Responsibilities.

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Your Rights

You have the right to:

• Get a copy of your paper or electronic medical record
• Correct your paper or electronic medical record
• Request confidential communication
• Ask us to limit the information we share
• Get a list of those with whom we’ve shared your information
• Get a copy of this privacy notice
• Choose someone to act for you
• File a complaint if you believe your privacy rights have been violated

Your Choices

You have some choices in the way that we use and share information as we:

• Tell family and friends about your condition
• Provide disaster relief
• Include you in a hospital directory
• Provide mental health care
• Market our services and sell your information
• Raise funds

Our Uses and Disclosures

We may use and share your information as we:

Treat you Run our organization Bill for your services Help with public health and safety issues Do research Comply with the law Respond to organ and tissue donation requests Work with a medical examiner or funeral director Address workers’ compensation, law enforcement, and other government requests Respond to lawsuits and legal actions

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.
• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.
• We will say “yes” to all reasonable requests.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say “no” if it would affect your care.
• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a list of those with whom we’ve shared information

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared it with, and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.
• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information on page 1.
• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
• We will not retaliate against you for filing a complaint.

 

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care
• Share information in a disaster relief situation
• Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes

In the case of fundraising:

• We may contact you for fundraising efforts, but you can tell us not to contact you again.

 

Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways.

Uses and Disclosures Of Protected Information for Treatment, Payment and Operation:

Western Iowa Endodontics requests that you sign a General Consent for Treatment form annually or whenever necessary to keep your medical record accurate and up-to-date. This Consent allows the organization to use or disclose your health information for purposes relating to treatment, payment or healthcare operations, as follows:

For treatment. We can use your health information and share it with other professionals who are treating you. Information obtained by an assistant, physician, health educator, and other members of your healthcare team will be documented in your record and will be used to determine the appropriate course of treatment for your particular issues, problems, or concerns, as well as to ensure that there will be continuity when transitions in your care occur. Your record may also contain copies of results from tests performed in the Clinic (e.g. laboratory and radiology studies) and correspondence from other healthcare professionals who have been or are treating you outside the Clinic. We may share your medical information with other physicians or other health care providers who will provide services that we do not provide, or we may share this information with a pharmacist who needs it to dispense a prescription to you, or a laboratory that performs a test for you. Hence, your physician will have an accurate, timely, and complete picture of your medical history and overall health condition when viewing your PHI and will be better able to treat your current medical problems safely. 
  
For payment. We can use and share your dental information to bill and get payment from dental plans and other payers. Following your treatment, a bill for services rendered is sent to you or to a third party payer (e.g. insurance company, health plan, etc.). The information on the bill may include information that identifies you, as well as your diagnosis, any procedure performed, and medications and supplies used. However, you may request that PHI associated with that portion of your healthcare for which you paid out-of-pocket not be disclosed to your health plan or insurance company.

For our operations. We can use and share your health information to run our practice, improve care, and plan for the future. We may use and disclose information about you to keep Western Iowa Endodontics in operation. Dental staff, the risk manager, quality management, or members of the process and quality improvement team may use information in your medical record to assess the care and outcomes in your case and others like it. This information will then be used to enhance the quality and improve the effectiveness of the healthcare and services we provide all our patients. We may also use and disclose PHI when necessary for medical reviews, attorney services and legal audits, including fraud and abuse detection and compliance programs, as well as business planning and facility management.

For working with our business associates. There are services provided in our organization through agreements with contractors or “business associates.” Examples include billing services that perform invoicing services for us; outside transcription services that transcribe physician dictations; and consultants we may hire to assist us in various aspects of health care administration. When these services are contracted, we may disclose your health information to such business associates and subcontractors so that they can perform the job they are contracted to do.

For notifications and reminders. We may contact you by postal mail, e-mail, or telephone in order to remind you of an upcoming appointment or to inform you about test results.Western Iowa Endodontics takes privacy and security matters very seriously, and in the event of a privacy violation or security breach involving your PHI, we are also obligated to notify you in accordance with Federal regulations and/or State law.

For communicating with your family and patient representatives. We can use your health information for internal and external communications. Using their best judgment and your authorization, healthcare professionals may disclose PHI to your family member, patient representative, or any other person you identify as involved in your personal care or bill payment.

For informing funeral directors, medical examiners, and coroners. We can share health information when a patient expires. We may disclose dental information to medical examiners or funeral directors consistent with applicable law in order to assist them in performing duties involving deceased patients.

For addressing Workers’ Compensation. We can use and share PHI when reporting on Workers’ Compensation cases. We may disclose dental information to the extent authorized by and to the extent necessary to comply with laws relating to disability involving Workers’ Compensation and other similar programs established by law.

For reporting cases pertaining to public health. As required by law, we may disclose your dental information to public health officials or legal authorities charged with preventing or controlling disease, injury, or disability, as well as with helping to recall products. Such information may include, but is not limited to, the reporting of abuse or neglect or domestic violence; the reporting of communicable diseases; and the reporting of reactions to medications or problems with products or devices. Additionally, we may share your PHI for preventing or reducing a serious threat to anyone’s health or safety.

For health oversight activities. We may disclose your health information to a health oversight agency for activities authorized by law. Oversight activities can include audits, investigations, inspections, depositions, subpoenas, surveys, licensure and disciplinary actions, criminal procedures or actions, or other activities necessary for the government to monitor programs, compliance with civil rights laws, and the health care system in general.

For law enforcement purposes. We may disclose your dental information if requested by law enforcement, military police, homeland security, presidential protective services, or legal authorities. If asked to do so by such law enforcement officials or legal agencies, we may release your PHI in the following circumstances: (a) suspicion of criminal conduct or potential death due to criminal conduct; or (b) in response to a warrant, summons, court order, administrative order, subpoena or other similar legal process.

For compliance with the law. We will share information about you if Federal or State laws require it. This type of disclosure includes sharing your PHI with the Department of Health and Human Services and, more specifically, with the Office of Civil Rights as evidence of compliance with HIPAA Privacy Rules.

 

Treat you

We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

 

Run our organization

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

 

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your dental insurance plan so it will pay for your services.

 

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues

We can share health information about you for certain situations such as:

• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers’ compensation, law enforcement, and other government requests

We can use or share health information about you:

• For workers’ compensation claims
• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.

Safeguards

It is the policy of this dental practice that appropriate physical safeguards will be in place to reasonably safeguard protected health information from any intentional or unintentional use or disclosure that is in violation of the HIPAA Privacy Rule.

These safeguards will include physical protection of premises and PHI, technical protection of PHI maintained electronically and administrative protection.  These safeguards will extend to the oral communication of PHI.  These safeguards will extend to PHI that is removed from the organization.

Business Associates
It is the policy of this medical practice that business associates must be
contractually bound to protect health information to the same degree as
set forth in this policy. It is also the policy of this organization that business
associates who violate their agreement will be dealt with first by an
attempt to correct the problem, and if that fails by termination of the
agreement and discontinuation of services by the business associate.

 

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

 

Other Instructions for Notice

• Effective Date of this Notice: 10/26/2016
• Privacy Officer: Jason Bouska 712-256-9943
• We never market or sell personal information