Notice of Privacy Practices

This Notice is effective on August 15, 2013

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.

This Notice of Privacy Practices identifies the general ways your Protected Health Information (PHI) can be used or disclosed by The Dental Spa Group. The Dental Spa Group uses PHI about you for treatment, to obtain payment for treatment, for administrative purposes, to evaluate the quality of care that you receive, and any other use required by law. “PHI” is the individually identifiable personal health information found in your medical and billing records. This information can be transmitted or maintained in any form by The Dental Spa Group. This Notice describes your legal rights regarding your protected health information. It also informs you of the legal duties and privacy practices of The Dental Spa Group. We must follow the privacy practices that are described in this Notice (which may be amended from time to time).

A. The Dental Spa Group may use and disclose PHI without your written authorization for certain purposes as described below. The examples provided in each category are not meant to be exhaustive, but instead are meant to describe the types of uses and disclosures that are permissible under federal and state law.
1. Treatment: We may use and disclose PHI in order to provide treatment to you. For example, we may use PHI including your medication history to diagnose, treat, and provide medical services to you. In addition, we may disclose PHI to other health care providers involved in your treatment.
2. Payment: Under federal law we may use or disclose PHI so that services you receive are appropriately billed to, and payment is collected from, your health plan. By way of example, we may disclose PHI to permit your health plan to take certain actions before it approves or pays for treatment services. We may contact the Guarantor for your visit in order to obtain payment.
3. Health Care Operations: We may use or disclose your PHI in order to support our business activities. These activities include, but are not limited to business associates, quality assessment activities, internal investigations, performance reviews, and training employees. In addition, we will use a sign-in sheet at the registration desk where you will be asked to provide your name and date of birth. We may also call you by name in the waiting room when the physicians ready to see you. We may use or disclose your PHI to contact you to remind you of an appointment, to notify you of test results, to inform you of health-related services that may be of interest to you, and to check on your treatment, progress, and satisfaction with our services.
4. Required or Permitted by Law: As required by Law, Public Health issues as required by law, Communicable Diseases, Health Oversight, Abuse or Neglect, Food and Drug Administration requirements, Legal proceedings, Law Enforcement, Coroners, Funeral Directors, Organ Donation, Research, Criminal Activity, Military Activity, National Security, Worker’s Compensation, Inmates, and other Required Uses and Disclosures. Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services.
5. Authorization for Other Disclosures: We will not use or disclose your protected health information, except as described throughout this document, unless you authorize us, in writing, to do so. You can revoke an authorization at any time, in writing. If you revoke an authorization, we will no longer use or disclose your PHI for the purpose covered by the authorization. However, we are unable to take back any uses or disclosures already made with your authorization. Specific examples of uses or disclosures requiring authorization include: use of psychotherapy notes, marketing activities, the sale of your PHI and most non-treatment uses and disclosures for which we are compensated and for any other uses and disclosures of PHI not described in this Joint Notice of Privacy Practices
B. Permissible Uses and Disclosures That May Be Made Without Your Authorization, But For Which You Have An Opportunity to Object.
1. Family and Other Persons Involved in Your Care. We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience to make reasonable inferences of your best interest in allowing a person to pick up filled prescription ns, medical supplies, x-rays, or other similar forms of health information.
2. Disaster or Relief Efforts. We may use or disclose protected health information to a public or private entity authorized by law or its charter to assist in disaster relief efforts for the purpose of coordinating notification of family members of your location, general condition, or death.
C. Other permitted and required uses and disclosures: Use or Disclose of your PHI for marketing or sale of your PHI to third parties, will be made only with your authorization . Once given, you may withdraw authorization at any time in writing.
A. Right to Inspect and Copy. You may request access to your medical records and billing records maintained by us in order to inspect and request copies of the records. All requests for access must be made in writing. Under limited circumstances, we may deny access to your records. Under federal law, you may not inspect or copy psychotherapy notes, information compiled in anticipation of, or use in, a legal proceeding, and PHI that is otherwise prohibited. We may charge a fee for the costs of copying and sending you any records requested.
B. Right to Alternative Communications. You may request, and we will accommodate, any reasonable written request for you to receive PHI by alternative means or communication or at alternative locations.
C. Right to Request Restrictions. You may ask us not to use or disclose any part of your PH I for the purposes of treatment, payment or health care operations. Your request must be in writing and state the specific restriction requested and to whom you want the restriction to apply. If you have paid for your services in full and ask us not to disclose your visit to your insurance company, we will honor that request. We are not required to agree to any other restriction that you may request.
D. Right to Accounting of Disclosures. Upon written request, you may obtain an accounting of certain disclosures of PHI made by us in the last six years. This right applies to disclosures for purposes other than treatment, payment or health care operations, excludes disclosures made to you or disclosures otherwise authorized by you, and is subject to other restrictions and limitations. We are required by law to notify you if your unsecured PHI is breached.
E. Right to Request Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances. If we deny your written request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
F. Right to Obtain Notice. You have the right to obtain a paper copy of this Notice by submitting a request to the Compliance Officer found atop of this Notice.
G. Questions and Complaints. If you desire further information about your privacy rights. or are concerned that we have violated your privacy rights, you may contact the Compliance Officer. You may also file a written complaint with the Director, Office of Civil Rights of the U.S. Department of Health and Human Services. We will not retaliate against you if you file a complaint with the Director or with our office. To Report a Complaint: If you believe your PHI privacy rights have been violated, you can file a complaint with us by mail, at the address provided at the top of this Notice. You may also file a complaint with the Secretary of the United States Department of Health and Human Services, Office of Civil Rights, by completing a Health Information Privacy Complaint Form (available at ) and sending it to the applicable OCR Regional Office listed on the form, or by calling 1-800-368-1019 for instructions and contact information. There will not be any penalty or retaliation against you for making a complaint to us or to the Department of Health and Human Services.

III. Changes to this Notice. We may change the terms of this Notice at any time. If we change this Notice, we may make the new notice terms effective for all PHI that we maintain, including any information created or received prior to issuing the new notice. If we change this Notice, we will post the revised notice in the waiting area of our office and on our website. You may also obtain any revised notice by contacting the center ‘s Compliance Officer information atop of this notice.

If you have any questions, would like to request a copy of this notice, need information regarding our legal duties and privacy practices, or how to exercise any of your PHI rights listed in this Notice, or need assistance with exercising your right to “opt-out” from any disclosure, please contact the Compliance Officer atop of this Notice.

Compliance Officer Contact: Alan Lavin | (610) 306-3069 | [email protected]

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