THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
Our Legal Duty
Florida law and the Health Insurance Portability & Accountability Act of 1996 (HIPAA) require us to maintain the confidentiality of all your health-care records and other individually identifiable health information used by or disclosed to us in any form, whether electronically, on paper, or orally (“PHI” or Protected Health Information). HIPAA is a federal law that gives you significant new rights to understand and control how your health information is used. HIPAA and Florida law provide penalties for covered entities and records owners, respectively, that misuse or improperly disclose PHI.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Any changes or revisions will be effective when the new notice is posted.
Our doctor, clinical staff, Business Associates (outside contractors we hire), employees and other office personnel follow the policies and procedures set forth in this notice. If your regular doctor is unavailable to assist you (e.g. illness, on-call coverage, vacation, etc), we may provide you with the name of another health-care provider outside our practice for you to consult with by telephone. If we do so, that provider will follow the policies and procedures set forth in this notice or those established for his or her practice, so long as they substantially conform to those for our practice.
Starting April 14, 2003, HIPAA requires us to provide you with this Notice of our legal duties and the privacy practices we are required to follow when you first come into our office for health-care services. If you have any questions about this Notice, please ask to speak to our privacy officer, (April Kesterson) at 561-333-3055, april@simonorthodontics.com.
Our Rules on How We May Use and Disclose Your Protected Health Information
Documentation: You will be asked to sign a Consent form when you receive this Notice of Privacy Practices. You may take back or revoke your Consent at any time (unless we already have acted based on it) by submitting our Revocation form to us in writing. In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.
General Rule: If you do not sign our consent form or if you revoke it, as a general rule (subject to exceptions described below), we cannot in any manner use or disclose to anyone (excluding you, but including payors and Business Associates) your PHI or any other information in your medical record. Under Florida law, we are unable to submit claims to payors under assignment of benefits without your signature on our consent form.
Payment: We may use and disclose your health information to obtain payment for services we provide to you, to bill or collect payment from you, an insurance company, a managed-care organization, a health-benefits plan or another third party.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. We may contact you by telephone, mail or otherwise remind you of scheduled appointments, we may leave messages with whomever answers your telephone or e-mail to contact us (but we will not give out detailed PHI), we may call you by name from the waiting room, we may ask you to put your name on a sign-in sheet. If you prefer that we not contact you with appointment reminders or information about treatment alternatives or health-related products and services, please notify us in writing and we will not use or disclose your PHI for these purposes.
Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you verbally agree that we may do so, we give you an opportunity to object and you do not; we reasonably assume, based on our professional judgment and the surrounding circumstances, that you do not object (e.g., you bring someone with you into the operatory or exam room during treatment or into the conference area when we are discussing your PHI); we reasonably infer that it is in your best interest (e.g., to allow someone to pick up your records because they knew you were our patient and you asked them in writing with your signature to do so); or it is an emergency situation involving you or another person (e.g., your minor child or ward) and, respectively, you cannot consent to your care because you are incapable of doing so or you cannot consent to the other person’s care because, after a reasonable attempt, we have been unable to locate you. In these emergency situations we may, based on our professional judgment and the surrounding circumstances, determine that disclosure is in the best interests of you or the other person, in which case we will disclose PHI, but only as it pertains to the care being provided and we will notify you of the disclosure as soon a possible after the care is completed.
Persons Involved In 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 with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.
Office Policies: We may use your name on our monthly birthday list; use photos without names for our photo book, Patients in the News, Meet Our Patients bulletin board, web site; some information may be seen or overheard in our open treatment area, reception area or on computer screens. Information may be sent to orthodontic laboratories when fabricating appliances.
Required by Law: We may use or disclose your health information when we are required to do so by law; when necessary for public health reasons (e.g., prevention or control of disease, injury or disability; reporting information such as adverse reactions to anesthesia; in effective or dangerous medications or products; suspected abuse, neglect or exploitation of children, disabled adults or the elderly; or domestic violence); for judicial and administrative proceedings and law enforcement purposes; for workers’ compensations purposes;
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.
Minimum Necessary Rule: Our staff will not use or access your PHI unless it is necessary to do their jobs. Also, we disclose to others outside our staff only as much of your PHI as is necessary to accomplish the recipient’s lawful purposes.
Incidental Disclosure Rule: We will take reasonable administrative, technical and security safeguards to ensure the privacy of your PHI when we use or disclose it (e.g., we require employees to talk softly when discussing PHI with you, we use computer passwords and change them periodically (e.g., when an employee leaves us), we allow access to areas where PHI is stored or filed only when we are present to supervise and prevent unauthorized access).
Business Associate Rule: Business Associates and other third parties(if any) that receive your PHI from us will be prohibited from re-disclosing it unless required to do so by law or you give prior express written consent to the re-disclosure. Nothing in our Business Associate agreement will allow our Business Associate to violate this re-disclosure prohibition.
Super-confidential Information Rule: If we have PHI about you regarding HIV testing, alcohol- or substance-abuse diagnosis and treatment, or psychotherapy and mental-health records (super-confidential information under the law), we will not disclose it under the General or Health-care Treatment, Payment and operations Rules (see above) without you first signing and properly completing our consent form (i.e., you specifically must initial the type of super-confidential information we are allowed to disclose). If you do not specifically authorize disclosure by initialing the super-confidential information, we will not disclose it unless authorized under federal or state law to do so), we will comply with state and federal law that requires us to warn the recipient in writing that re-disclosure is prohibited.
Changes to Privacy Policies Rule: We reserve the right to change our privacy practices (by changing the terms of this Notice) at any time as authorized by law. The changes will be effective immediately upon us posting.
Authorization Rule: We will not use or disclose your PHI for any purpose or to any person other than as stated in the rules above without your signature on a specifically worded, written Authorization form (not a Consent or an Acknowledgement). If we need your Authorization, we must obtain it on our Authorization form, which is separate from any Consent or Acknowledgement we may have obtained from you. We will not condition treatment on whether or not you sign the Authorization.
Your Rights Regarding Your Protected Health Information
Access: You have the right to see and get a copy of your PHI including, but not limited to, medical and billing records by submitting a written request to our privacy officer on our Request to Inspect, Copy or Summarize form. We may charge you a fee not to exceed Florida law to recover our costs to duplicate or summarize your PHI. We will respond to requests in a timely manner, without delay for legal review, in less than 30 days if submitted in writing on our form or otherwise, and in 10 business days or less if malpractice litigation or pre-suit production is involved.
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. Your request must be in writing and specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you 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.
Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.
To Complain or Get More Information: We will follow our rules as set forth in this Notice. If you want more information or if you believe your privacy rights have been violated (e.g., you disagree with a decision of ours about inspection/copying, amendment/correction, accounting of disclosures, restrictions or alternative communications), we want to make it right. We never will penalize you for filing a complaint. To do so, please file a formal, written complaint within 180 days with:
The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Ave., S.W.
Washington, D.C. 20201
(877)696-6775
Or, submit a written Complaint form to us at the following address:
April Kesterson
c/o Dr. David Simon
10115 Forest Hill Blvd., Suite 301
Wellington, FL 33414
561-333-3055
You may get our complaint form by calling our privacy officer.
Unresolved complaints will be subject to binding arbitration under the rules of the American Arbitration Association in Wellington, Florida with each party to pay their own attorney’s fees and costs.