Kurt M. Halum, DMD, PC
2303 45th Street
Highland, Indiana 46322
Privacy Officer: Nicole Plott
Effective Date: 01/18/2016
THIS NOTICE DESCRIBES HOW DENTAL INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED AND HOW
YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.
We understand the importance of privacy and are
committed to maintaining the confidentiality of your
medical/ dental information. We make a record of the
dental care we provide and may receive such records from
others. We use these records to provide or enable other
health care providers to provide quality dental care, to
obtain payment for services provided to you as allowed by
your health plan and to enable us to meet our professional
and legal obligations to operate this dental practice
properly. We are required by law to maintain the privacy of
protected health information, to provide individuals with
notice of our legal duties and privacy practices with respect
to protected health information, and to notify affected
individuals following a breach of unsecured protected
health information. This notice describes how we may use
and disclose your medical/ dental information. It also
describes your rights and our legal obligations with respect
to your medical/ dental information. If you have any
questions about this Notice, please contact our Privacy
Officer listed above.
A. How This Dental Practice May Use or Disclose
Your Health Information
This dental practice collects health information about
you and stores it in a chart [and/or on a computer][and in
an electronic health record/personal health record]. This
is your dental record. The dental record is the property of
this dental practice, but the information in the dental
record belongs to you. The law permits us to use or
disclose your health information for the following
purposes:
1. Treatment. We use medical/ dental information
about you to provide your dental care. We disclose
medical/ dental information to our employees and others
who are involved in providing the care you need. For
example, we may share your medical/ dental information with other dentists 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. We may also disclose medical/ dental
information to members of your family or others who can
help you when you are sick or injured, or after you die.
2. Payment. We use and disclose medical/ dental
information about you to obtain payment for the services
we provide. For example, we give your health plan the
information it requires before it will pay us. We may also
disclose information to other health care providers to
assist them in obtaining payment for services they have
provided to you.
3. Health Care Operations. We may use and disclose
medical/ dental information about you to operate this
dental practice. For example, we may use and disclose
this information to review and improve the quality of care
we provide, or the competence and qualifications of our
professional staff. Or we may use and disclose this
information to get your dental plan to authorize services
or referrals. We may also use and disclose this
information as necessary for dental reviews, legal services
and audits, including fraud and abuse detection and
compliance programs and business planning and
management. We may also share your medical/ dental
information with our "business associates," such as our
billing service, that perform administrative services for us.
We have a written contract with each of these business
associates that contains terms requiring them and their
subcontractors to protect the confidentiality and security
of your protected health information. We may also share
your information with other health care providers, health
care clearinghouses or dental plans that have a
relationship with you, when they request this information
to help them with their quality assessment and
improvement activities, their patient-safety activities,
their population-based efforts to improve health or
reduce health care costs, their protocol development, case
management or care-coordination activities, their review
of competence, qualifications and performance of health
care professionals, their training programs, their
accreditation, certification or licensing activities, or their
health care fraud and abuse detection and compliance
efforts.
4. Appointment Reminders. We may use and disclose
medical/ dental information to contact and remind you
about appointments. If you are not home, we may leave
this information on your answering machine or in a
message left with the person answering the phone.
5. Sign In Sheet. We may use and disclose medical/
dental information about you by having you sign in when
you arrive at our office. We may also call out your name
when we are ready to see you.
6. Notification and Communication With Family. We
may disclose your health information to notify or assist in
notifying a family member, your personal representative
or another person responsible for your care about your
location, your general condition or, unless you had
instructed us otherwise, in the event of your death. In the
event of a disaster, we may disclose information to a relief
organization so that they may coordinate these
notification efforts. We may also disclose information to
someone who is involved with your care or helps pay for
your care. If you are able and available to agree or object,
we will give you the opportunity to object prior to making
these disclosures, although we may disclose this
information in a disaster even over your objection if we
believe it is necessary to respond to the emergency
circumstances. If you are unable or unavailable to agree
or object, our health professionals will use their best
judgment in communication with your family and others.
7. Marketing. Provided we do not receive any
payment for making these communications, we may
contact you to give you information about products or
services related to your treatment, case management or
care coordination, or to direct or recommend other
treatments, therapies, health care providers or settings of
care that may be of interest to you. We may similarly
describe products or services provided by this practice
and tell you which health plans this practice participates
in. We may also encourage you to maintain a healthy
lifestyle and get recommended tests, participate in a
disease management program, provide you with small
gifts, tell you about government sponsored health
programs or encourage you to purchase a product or
service when we see you, for which we may be paid.
Finally, we may receive compensation, which covers our
cost of reminding you to take and refill your medication,
or otherwise communicate about a drug or biologic that is
currently prescribed for you. We will not otherwise use or
disclose your medical/ dental information for marketing
purposes or accept any payment for other marketing
communications without your prior written authorization.
The authorization will disclose whether we receive any
compensation for any marketing activity you authorize,
and we will stop any future marketing activity to the
extent you revoke that authorization.
8. Sale of Health Information. We will not sell your
health information without your prior written
authorization. The authorization will disclose that we will
receive compensation for your health information if you
authorize us to sell it, and we will stop any future sales of
your information to the extent that you revoke that
authorization.
9. Required by Law. As required by law, we will use
and disclose your health information, but we will limit our
use or disclosure to the relevant requirements of the law.
When the law requires us to report abuse, neglect or
domestic violence, or respond to judicial or administrative
proceedings, or to law enforcement officials, we will
further comply with the requirement set forth below
concerning those activities.
10. Public Health. We may, and are sometimes
required by law, to disclose your health information to
public health authorities for purposes related to:
preventing or controlling disease, injury or disability;
reporting child, elder or dependent adult abuse or neglect;
reporting domestic violence; reporting to the Food and
Drug Administration problems with products and
reactions to medications; and reporting disease or
infection exposure. When we report suspected elder or
dependent adult abuse or domestic violence, we will
inform you or your personal representative promptly
unless in our best professional judgment, we believe the
notification would place you at risk of serious harm or
would require informing a personal representative we
believe is responsible for the abuse or harm.
11. Health Oversight Activities. We may, and are
sometimes required by law, to disclose your health
information to health oversight agencies during the
course of audits, investigations, inspections, licensure and
other proceedings, subject to the limitations imposed by
law.
12. Judicial and Administrative Proceedings. We may,
and are sometimes required by law, to disclose your
health information in the course of any administrative or
judicial proceeding to the extent expressly authorized by a
court or administrative order. We may also disclose
information about you in response to a subpoena,
discovery request or other lawful process if reasonable
efforts have been made to notify you of the request and
you have not objected, or if your objections have been
resolved by a court or administrative order.
13. Law Enforcement. We may, and are sometimes
required by law, to disclose your health information to a
law enforcement official for purposes such as identifying
or locating a suspect, fugitive, material witness or missing
person, complying with a court order, warrant, grand jury
subpoena and other law enforcement purposes.
14. Coroners. We may, and are often required by
law, to disclose your health information to coroners in
connection with their investigations of deaths.
15. Public Safety. We may, and are sometimes
required by law, to disclose your health information to
appropriate persons in order to prevent or lessen a
serious and imminent threat to the health or safety of a
particular person or the general public.
16. Specialized Government Functions. We may
disclose your health information for military or national
security purposes or to correctional institutions or law
enforcement officers that have you in their lawful custody.
17. Workers' Compensation. We may disclose your
health information as necessary to comply with workers’
compensation laws. For example, to the extent your care
is covered by workers' compensation, we may be required
make periodic reports to your employer about your
condition. We are also required by law to report cases of
occupational injury or occupational illness to the
employer or workers' compensation insurer.
18. Change of Ownership. In the event that this
dental practice is sold or merged with another
organization, your health information/record will become
the property of the new owner, although you will maintain
the right to request that copies of your health information
be transferred to another dentist or dental group.
19. Breach Notification. In the case of a breach of
unsecured protected health information, we will notify
you as required by law. If you have provided us with a
current e-mail address, we may use e-mail to
communicate information related to the breach. In some
circumstances our business associate may provide the
notification. We may also provide notification by other
methods as appropriate. [Note: Only use e-mail
notification if you are certain it will not contain PHI and it
will not disclose inappropriate information. For example if
your e-mail address is "digestivediseaseassociates.com"
an e-mail sent with this address could, if intercepted,
identify the patient and their condition.]
B. When This Dental Practice May Not Use or
Disclose Your Health Information
Except as described in this Notice of Privacy Practices,
this dental practice will, consistent with its legal obligations, not use or disclose health information which
identifies you without your written authorization. If you
do authorize this dental practice to use or disclose your
health information for another purpose, you may revoke
your authorization in writing at any time.
C. Your Health Information Rights
1. Right to Request Special Privacy Protections. You
have the right to request restrictions on certain uses and
disclosures of your health information by a written
request specifying what information you want to limit,
and what limitations on our use or disclosure of that
information you wish to have imposed. If you tell us not
to disclose information to your commercial health plan
concerning health care items or services for which you
paid for in full out-of-pocket, we will abide by your
request, unless we must disclose the information for
treatment or legal reasons. We reserve the right to accept
or reject any other request, and will notify you of our
decision.
2. Right to Request Confidential Communications.
You have the right to request that you receive your health
information in a specific way or at a specific location. For
example, you may ask that we send information to a
particular e-mail account or to your work address. We
will comply with all reasonable requests submitted in
writing which specify how or where you wish to receive
these communications.
3. Right to Inspect and Copy. You have the right to
inspect and copy your health information, with limited
exceptions. To access your medical/ dental information,
you must submit a written request detailing what
information you want access to, whether you want to
inspect it or get a copy of it, and if you want a copy, your
preferred form and format. We will provide copies in
your requested form and format if it is readily producible,
or we will provide you with an alternative format you find
acceptable, or if we can’t agree and we maintain the
record in an electronic format, your choice of a readable
electronic or hardcopy format. We will also send a copy to
any other person you designate in writing. We will charge
a reasonable fee which covers our costs for labor,
supplies, postage, and if requested and agreed to in
advance, the cost of preparing an explanation or
summary. We may deny your request under limited
circumstances. If we deny your request to access your
child's records or the records of an incapacitated adult
you are representing because we believe allowing access
would be reasonably likely to cause substantial harm to
the patient, you will have a right to appeal our decision.
4. Right to Amend or Supplement. You have a right to
request that we amend your health information that you
believe is incorrect or incomplete. You must make a
request to amend in writing, and include the reasons you
believe the information is inaccurate or incomplete. We
are not required to change your health information, and
will provide you with information about this dental
practice's denial and how you can disagree with the
denial. We may deny your request if we do not have the
information, if we did not create the information (unless
the person or entity that created the information is no
longer available to make the amendment), if you would
not be permitted to inspect or copy the information at
issue, or if the information is accurate and complete as is.
If we deny your request, you may submit a written
statement of your disagreement with that decision, and
we may, in turn, prepare a written rebuttal. All
information related to any request to amend will be
maintained and disclosed in conjunction with any
subsequent disclosure of the disputed information.
5. Right to an Accounting of Disclosures. You have a
right to receive an accounting of disclosures of your health
information made by this dental practice, except that this
dental practice does not have to account for the
disclosures provided to you or pursuant to your written
authorization, or as described in paragraphs 1
(treatment), 2 (payment), 3 (health care operations), 6
(notification and communication with family) and 18
(specialized government functions) of Section A of this
Notice of Privacy Practices or disclosures for purposes of
research or public health which exclude direct patient
identifiers, or which are incident to a use or disclosure
otherwise permitted or authorized by law, or the
disclosures to a health oversight agency or law
enforcement official to the extent this dental practice has
received notice from that agency or official that providing
this accounting would be reasonably likely to impede their
activities.
6. Right to a Paper or Electronic Copy of this Notice.
You have a right to notice of our legal duties and privacy
practices with respect to your health information,
including a right to a paper copy of this Notice of Privacy
Practices, even if you have previously requested its
receipt by e-mail.
If you would like to have a more detailed explanation of
these rights or if you would like to exercise one or more of
these rights, contact our Privacy Officer listed at the top of
this Notice of Privacy Practices.
D. Changes to this Notice of Privacy Practices
We reserve the right to amend this Notice of Privacy
Practices at any time in the future. Until such amendment
is made, we are required by law to comply with the terms
of this Notice currently in effect. After an amendment is
made, the revised Notice of Privacy Protections will apply
to all protected health information that we maintain,
regardless of when it was created or received. We will
keep a copy of the current notice posted in our reception
area, and a copy will be available at each appointment. We
will also post the current notice on our website.
E. Complaints
Complaints about this Notice of Privacy Practices or
how this dental practice handles your health information
should be directed to our Privacy Officer listed at the top
of this Notice of Privacy Practices.
If you are not satisfied with the manner in which this
office handles a complaint, you may submit a formal
complaint to:
Midwest Region - (Illinois, Indiana, Iowa, Kansas,
Michigan, Minnesota, Missouri, Nebraska, Ohio,
Wisconsin)
Celeste Davis
Office for Civil Rights
U.S. Department of Health and Human Services
233 N. Michigan Ave., Suite 240
Chicago, IL 60601
Voice Phone (800) 368-1019
FAX (202) 619-3818
TDD (800) 537-7697
OCRMail@hhs.gov
The complaint form may be found at
www.hhs.gov/ocr/privacy/hipaa/complaints/hipcomplaint.pdf
You will not be penalized in any way for filing a complaint.
