Effective date of notice: July 1st, 2015
NOTICE OF PRIVACY PRACTICES
Abra DiLisio, D.D.S Jessica Levy, D.D.S.
120 East Ave.
Norwalk, CT 06851
Abra DiLisio: office contact person
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.
We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. This Notice describes how we protect your health information and what rights you have regarding it.
TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS
The most common reason why we use or disclose your health information is for treatment, payment or health care operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you; examining your teeth, mouth, and oral health; prescribing medications and faxing them to be filled; prescribing dental appliances and dental prostheses; showing you treatment options; referring you to another dentist for specialty care; or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your dental or medical care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). “Health care operations” mean those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records.
We routinely use your health information inside our office for these purposes without any special permission. If we need to disclose your health information outside of our office for these reasons, [we will] [we usually will not] ask you for special written permission.
[We will ask for special written permission in the following situations: anything related to HIV/AIDS status, any sale of information, any use of information for marketing or fundraising purposes, and ____________________ .]
USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION
In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:
· when a state or federal law mandates that certain health information be reported for a specific purpose;
· for public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices;
· disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;
· uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws;
· disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
· disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else;
· disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations;
· uses or disclosures for health related research;
· uses and disclosures to prevent a serious threat to health or safety;
· uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service;
· disclosures of de-identified information;
· disclosures relating to worker’s compensation programs;
disclosures of a “limited data set” for research, public health, or health care operations;
incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
disclosures to “business associates” who perform health care operations for us and who commit to respect the privacy of your health information.
We may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. We may also call or write to notify you of other treatments or services available at our office that might help you. Unless you tell us otherwise, we will mail you an appointment reminder on a post card, and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not home.
OTHER USES AND DISCLOSURES
We will not make any other uses or disclosures of your health information unless you sign a written “authorization form.” The content of an “authorization form” is determined by federal law. Sometimes, we may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate the process if it’s your idea for us to send your information to someone else. Typically, in this situation you will give us a properly completed authorization form, or you can use one of ours.
If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing. Send them to the office contact person named at the beginning of this Notice.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
The law gives you many rights regarding your health information. You can:
· ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want. We must honor a restriction not to send information to a health care plan regarding any service for which you have already made full payment. To ask for a restriction, send a written request to the office contact person at the address, fax or E Mail shown at the beginning of this Notice.
· ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using E mail to your personal E Mail address. We will accommodate these requests if they are reasonable, and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice.
· ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 10 days of asking us. You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally available. If you want to review or get photocopies of your health information, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice.
· ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information, and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30 day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to the office contact person at the address, fax or E mail shown at the beginning of this Notice.
· get a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want). By law, the list will not include: disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30 day extension of time if we notify you of the extension in writing. If you want a list, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice.
· get additional paper copies of this Notice of Privacy Practices upon request. It does not matter whether you got one electronically or in paper form already. If you want additional paper copies, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice.
be notified by us in a timely manner of any breach of the privacy and confidentiality of your unsecured protected health information, which we will provide to you in accordance with law and take all appropriate measures to address
OUR NOTICE OF PRIVACY PRACTICES
By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice in our office, have copies available in our office, and post it on our Web site.
If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax or E mail shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone.
FOR MORE INFORMATION
If you want more information about our privacy practices, call or visit the office contact person at the address or phone number shown at the beginning of this Notice.
We will take reasonable steps to provide free-of-charge language assistance services to people who speak languages we are likely to hear in our practice and who don’t speak English well enough to talk to us about the dental care we are providing. Spanish: Tomaremos acciones razonables para proporcionar servicios de asistencia lingüística gratuitos a aquellas personas cuyo lenguaje escuchemos frecuentemente en nuestro consultorio y que no hablen un inglés lo sufi cientemente bueno como para hablar con nosotros sobre el servicio odontológico que suministramos. Portuguese: Tomaremos acciones razonables para proporcionar servicios de asistencia lingüística gratuitos a aquellas personas cuyo lenguaje escuchemos frecuentemente en nuestro consultorio y que no hablen un inglés lo sufi cientemente bueno como para hablar con nosotros sobre el servicio odontológico que suministramos. Polish: Będziemy podejmować stosowne kroki, by zapewnić bezpłatne usługi wsparcia językowego dla ludzi, którzy rozmawiają językami, które my chcielibyśmy słyszeć w naszym gabinecie i dla tych, którzy nie mówią po angielsku na tyle dobrze, aby rozmawiać z nami o opiece stomatologicznej, którą zapewniamy. Chinese: 我们将有序地做到提供免费的语言服务使我们能听懂英语不好的人向我们咨询有关牙齿护理 Italian: Adotteremo le misure ragionevoli per fornire servizi di assistenza linguistica gratuiti a coloro che parlano lingue che sentiamo spesso sul posto di lavoro e che non parlano inglese abbastanza bene da poter discutere della cura dentale che stiamo fornendo. French: Nous prendrons les mesures raisonnables pour fournir des services d’assistance linguistique gratuits pour les individus qui parlent des langues que nous sommes susceptibles d’entendre durant nos séances et qui ne parlent pas suffi samment bien l’anglais pour discuter avec nous concernant les soins dentaires que nous fournissons. French Creole (Haitian Creole): Nou pral pran mezi rezonab pou bay sèvis asistans lang gratis pou moun ki pale lang nou pagen ide deyo ak ki pa pale angle byen ase pou pale ak nou sou swen dantè nou ap bay. Russian: Мы принимаем необходимые меры, чтобы предоставить бесплатные услуги переводчика для общения на языках, с которыми мы сталкиваемся в нашей практике с клиентами, которые не владеют английским языком достаточно, чтобы обсудить с нами стоматологическое обслуживание, которое мы предоставляем. Vietnamese: Chúng tôi sẽ thực hiện các bước cần thiết để cung cấp dịch vụ hỗ trợ ngôn ngữ miễn phí cho những người giao tiếp bằng những ngôn ngữ mà chúng tôi có thể nghe thấy tại phòng khám của mình và cho những người không có đủ trình độ tiếng Anh để thảo luận về dịch vụ chăm sóc nha khoa mà chúng tôi đang cung cấp. Arabic: Reproduction of this material by member dentists and their staff is permitted for non-commercial use in their dental offi ces, on their websites, and on publications and communications for purposes of compliance with the Section 1557 fi nal rule. Any other use, duplication or distribution by members or any other party requires the prior written approval of the American Dental Association. This material is for general reference purposes only and does not constitute legal advice. It covers only the Section 1557 fi nal rule tagline requirement, not other federal or state law. Changes in applicable laws or regulations may require revision. Dentists should contact qualifi ed legal counsel for legal advice, including advice pertaining to compliance with Section 1557 of the Affordable Care Act, and the U.S. Department of Health and Human Services rules and regulations. © 2016 American Dental Association. All rights reserved. POSTER PROVIDED WITH SUPPORT FROM: Korean: 저희는 적절한 조치를 통하여 언어 지원 서비스를 무료로 제공할 것입니다. 다만, 실제로 저희에게 관심이 있는 언어를 쓰지만 저희 치아 관리 서비스에 대해 의견을 줄 수 있을 만큼 영어로 의사소통이 원활하지 않는 경우로 한정합니다 Albanian: Do të marrim hapa të arsyeshëm për të ofruar shërbime falas për asistencë gjuhësore për njerëzit që fl asin gjuhë që ka të ngjarë të dëgjojmë në punën tone dhe që nuk fl asin anglisht aq mire sa të fl asin me ne për kujdesin dentar që ofrojmë. Hindi: हम उन व्यक्तियों को, जो कक ऐसी भाषाएं बोलिे हैं जो हम अपने अभ्यास में संभाविि रूप में सुनना चाहिे हैं और जो हमारे द्िारा प्रदान की जाने िाली डैंटल देखभाल के बारे में हमारे साथ उचचि ढंग से अंग्रेजी नहीं बोलिे, मुफ़ि् सेिाएं प्रदान करने के ललये उचचि कदम उठायेंगे। Tagalog: Gagawin namin ang mga makatwirang hakbang para maibigay namin ng walang bayad ang mga tulong na serbisyo sa wika para sa mga taong nagsasalita ng mga wikang karaniwan naming naririnig sa aming pagsasagawa at sa mga hindi bihasa sa pagsasalita ng Ingles na sasangguni sa amin tungkol sa pangangalaga ng ngipin na ibinibigay namin. Greek: Θα λάβουμε όλα τα αναγκαία μέτρα ώστε να παρέχουμε υπηρεσίες γλωσσικής βοήθειας δωρεάν-χωρίς-χρέωση στους ανθρώπους εκείνους που είναι πιθανόν ότι θα μιλούν στη μητρική τους γλώσσα κατά τη διάρκεια της εξέτασης και οι οποίοι δεν θα μιλούν τα αγγλικά αρκετά καλά ώστε να συνεννοηθούν με εμάς για την οδοντιατρική φροντίδα που παρέχουμε.