The information provided below illustrates the manner your protected health information could be accessed and released and what you need to know about this process. This important document should be reviewed thoroughly. Managing the privacy of your protected health information is extremely important to Preston Hollow Dental Specialists.
Preston Hollow Dental Specialists Legal Responsibilities: As mandated by Federal and state legal requirements your protected health information must be protected. As part of these regulations we are required to ensure you are aware of privacy policies, legal duties and your rights to your protected health information. This notice of privacy policies, outlined below, will be in effect for the duration and must be followed by our practice. This notice will be in effect until it is replaced and becomes effective 12/01/06.
We reserve the right to modify our privacy policies and the terms of this notice at any time and will make such modifications within the guidelines of the law. We reserve the right to make the modifications effective for all protected health information that we maintain, including protected health information we created or received before the changes were made. Changing this notice will precede all significant modifications. This notice will be available upon request.
Copies of this notice are available at your request. For your convenience information regarding how you can contact us is at the bottom of this notice.
PROTECTED HEALTH INFORMATION USE AND DISCLOSURE: Information regarding your health may be used and disclosed for the purpose of treatment, payment, and other healthcare operations.
Examples cited below further explain the use and disclosure process.
Treatment: Use and disclosure of your protected health information may be provided to a physician or other healthcare provider providing treatment to you. Your information may be electronically disclosed either by email or by submitting claim forms electronically to your insurance carrier.
Payment: Your protected health information may be used and disclosed to obtain payment for services we provided to you.
Healthcare Processes: We may use and disclose your protected healthcare information in relation to our healthcare processes. These processes include assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating provider performance and practitioners, conducting training programs, and accreditation, certification, licensing, or credentialing activities. Information may also be electronically disclosed by email or by submitting claim forms to your insurance carrier.
Your Authorization: At any time, you may provide written authorization for the use and disclosure of your protected health information for any purpose. You may revoke your written authorization at any time. The revocation must be in writing. If you revoke your authorization, it will not affect any use or disclosure made prior to the revocation.
Your protected healthcare information may be used and disclosed to you, as described in the Patient Rights section of this notice. In addition, your protected health information may be used and disclosed to a family member, friend, or another person to the extent necessary to assist you with your healthcare, but only with your authorization.
Person Involved in Care: To accommodate notification of your location, general condition, or death, your protected health information may be used or disclosed to a family member, personal representative, or another person responsible for your care. If you are present and object to such disclosure, you may do so. If you are incapacitated or emergency circumstances exist, we will use our professional judgment to disclose only the protected health information directly relevant to that person’s involvement in your healthcare. We may also use professional judgment and common practices to allow a person to pick up filled prescriptions, medical supplies, X-rays, or other similar items on your behalf.
Marketing Health-Related Services: The use of your protected health information for marketing communications is prohibited without your written authorization.
Required by Law: Your protected health information may be used or disclosed when required by law.
Abuse or Neglect: As required by law, if we believe you may be the victim of abuse, neglect, domestic violence, or another crime, your protected health information may be disclosed to the appropriate authorities. We may also disclose protected health information if necessary to prevent a serious threat to your health or safety or the health or safety of others.
National Security: Under certain circumstances, the military may require disclosure of healthcare information for armed forces personnel. Authorized federal authorities may also require disclosure of protected health information for national security activities, counterintelligence, or lawful intelligence purposes. Protected healthcare information may also be disclosed to correctional facilities or law enforcement authorities when legally authorized.
Appointment Reminders: Your protected healthcare information may be used to provide appointment reminders through voicemail messages, postcards, letters, or text messages.
PATIENT RIGHTS
Access: You have the right to review your protected health information, with limited exceptions. Upon request, we will provide your information in a format other than photocopies whenever reasonably possible.
Your request for access must be submitted in writing. You may obtain a Protected Health Information Access Form using the contact information provided at the end of this notice. We may charge a reasonable cost-based fee for copies and staff time. If you request paper copies, the fee is $2.00 per page plus $20.00 per hour for staff time required to locate and copy your records. Postage charges will apply if you request mailed copies. If you request an alternative format, a cost-based fee may also apply. A detailed explanation of applicable fees is available upon request.
Disclosure Accounting: You have the right to receive an accounting of disclosures of your protected health information made by us or our business associates for purposes other than treatment, payment, healthcare operations, and certain other permitted activities during the previous six years. Additional reasonable cost-based fees may apply if more than one request is made within a 12-month period.
Restrictions: You may request additional restrictions on the use or disclosure of your protected health information. We are not required to agree to every requested restriction. If we do agree, we will comply with the restriction unless emergency circumstances require otherwise.
Alternative Communication: You have the right to request that we communicate with you regarding your protected health information through alternative methods or at alternative locations. Requests must be submitted in writing and should include acceptable payment arrangements where applicable.
Amendment: You may submit a written request to amend your protected health information. Your request must include the reason for the proposed amendment. Under certain circumstances, we may deny your request.
Electronic Notice: If you receive this notice electronically, you are entitled to request and receive a paper copy at any time.
QUESTIONS AND COMPLAINTS
If you believe your protected health information has not been properly protected, if you disagree with a decision regarding access to your records, or if you have concerns about our response to a request for amendment, alternative communication, or disclosure, you have the right to file a complaint. You may also file a complaint with the U.S. Department of Health and Human Services. Upon request, we will provide the appropriate contact information for filing a complaint.
Protecting the privacy of your protected health information remains extremely important to us. If you file a complaint with the U.S. Department of Health and Human Services, we will not retaliate against you in any way. We are committed to addressing any questions, concerns, or complaints you may have.
Contact: Office Manager
Telephone: 214-691-5621
Address: 8411 Preston Rd., Ste. 850
City, State, Zip: Dallas, TX 75225
