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Privacy and Disclosures

NOTICE OF PRIVACY PRACTICES

This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

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. We must follow the privacy practices described in this Notice while it is in effect. This Notice takes effect 09/2013 and will remain in effect until we replace it.

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, and to make new Notice provisions effective for all protected health information that we maintain. When we make a significant change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently in our practice location, and we will provide copies of the new Notice upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

We may use and disclose your health information for different purposes, including treatment, payment, and health care operations. For each category, we have provided a description and an example. Some information—such as HIV-related information, genetic information, alcohol and drug abuse records, and mental health records—may be entitled to special confidentiality protections under applicable state or federal law. We will abide by these special protections as they pertain to applicable cases involving these types of records.

Treatment

We may use and disclose your health information for your treatment. For example, we may disclose your health information to a specialist providing treatment to you.

Payment

We may use and disclose your health information to obtain reimbursement for treatment and services you receive from us or another entity involved in your care. Payment activities include billing, claims management, and determining eligibility or coverage for insurance benefits. For example, we may send claims to your dental plan containing certain health information.

Healthcare Operations

We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operation uses may include quality assessment, improvement activities, training programs, and peer review activities.

Individuals Involved in Your Care or Payment for Your Care

We may disclose your health information to your family or friends or any other individual identified by you when they are involved in your care or in the payment for your care. Additionally, we may disclose information about you to a patient representative. If a person has the authority by law to make health care decisions for you, we will treat that patient representative the same way we would treat you with respect to your health information.

Disaster Relief

We may use or disclose your health information to assist in disaster relief efforts.

OTHER USES AND DISCLOSURES

Required by Law

We may use or disclose your health information when required to do so by law.

Public Health Activities

We may disclose your health information for public health activities, including disclosures to:

  • Prevent or control disease, injury, or disability

  • Report child abuse or neglect

  • Report reactions to medications or problems with products or devices

  • Notify a person of a recall, repair, or replacement of products or devices

  • Notify a person who may have been exposed to a disease or condition

  • Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence

National Security

We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances, and disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities.

Secretary of HHS

We will disclose your health information to the Secretary of the U.S. Department of Health and Human Services when required to investigate compliance with HIPAA.

Worker’s Compensation

We may disclose your PHI to the extent authorized by and necessary to comply with laws relating to workers’ compensation or similar programs.

Law Enforcement

We may disclose your PHI for law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order.

Health Oversight Activities

We may disclose your PHI to an oversight agency for activities authorized by law such as audits, investigations, inspections, and credentialing.

Judicial and Administrative Proceedings

If you are involved in a lawsuit or dispute, we may disclose your PHI in response to a court or administrative order, subpoena, discovery request, or other lawful process.

Research

We may disclose your PHI to researchers whose research has been approved by an institutional review board.

Coroners, Medical Examiners, and Funeral Directors

We may release PHI to coroners or medical examiners to identify a deceased person or determine cause of death, and to funeral directors as necessary for their duties.

Fundraising

We may contact you to provide information about sponsored activities, including fundraising. You may opt out of receiving such communications.

OTHER USES AND DISCLOSURES OF PHI

Authorization is required for uses and disclosures not described in this Notice, including use of psychotherapy notes, or disclosure of PHI for marketing or sale. You may revoke an authorization in writing.

YOUR HEALTH INFORMATION RIGHTS

Access

You have the right to look at or get copies of your health information. Requests must be in writing. Photocopies or electronic copies may be provided, including reasonable cost-based fees.

Disclosure Accounting

You have the right to receive an accounting of certain disclosures of your PHI. Requests must be submitted in writing. You may request an accounting once in a 12-month period at no charge.

Right to Request a Restriction

You may request restrictions on our use or disclosure of your PHI. We are not required to agree to all restrictions, except when required by law.

Alternative Communication

You may request that we communicate with you by alternative means or at alternative locations. Requests must be in writing.

Amendment

You may request that we amend your health information. Requests must be in writing and may be denied in certain circumstances. If denied, you will receive a written explanation.

Right to Notification of a Breach

You will receive notifications of breaches of your unsecured protected health information as required by law.

Electronic Notice

You may receive a paper copy of this Notice upon request, even if you agreed to receive it electronically.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions, please contact us.

If you believe your privacy rights have been violated, or if you disagree with a decision we made about your PHI, you may file a complaint with our office or with the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint.

CONTACT INFORMATION

Black Bear Family Dental
1628 30th Street NW
Bemidji, MN 56601
(218) 444-2004