Notice of Privacy Practices

CITY VIEW DENTAL JAMES P. POLERECKY, DDS 1415 HARNEY STREET, SUITE 100 OMAHA, NE 68102 PHONE (402)Omaha Office Phone Number 402-341-7576   FAX (402)402-341-8975

NOTICE OF PRIVACY PRACTICES


THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS NOTICE CAREFULLY

We are required by law to maintain the privacy of protected health information (PHI), to provide individuals with notice of our legal duties and privacy practices with respect to PHI, and to notify affected individuals following a breach of unsecured PHI. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect 2/1/2017.  You may request a copy of the notice at any time. We reserve the right to change our privacy practices and the terms of this notice at any time, provided these changes are permitted by applicable law, and to make new notice provisions effective for all PHI we maintain.  The new notice will be available upon request.


HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

Treatment. We may use and disclose your PHI for treatment to personnel in our office, as well as other healthcare professionals who are involved in your care. For example, we may disclose your PHI to a specialist providing treatment to you. Payment. We may use and disclose your PHI to obtain payment for the treatment and services you receive from us or another entity involved with your care. Payment activities include billing, collections, claims management, and determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party. For example, we may send claims to your dental health plan containing certain health information. Healthcare Operations. We may use and disclose your PHI in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, conducting training programs, accreditation, certification, licensing, and credentialing activities. For example, we may disclose your PHI to medical students who are performing work with our office, or to call your name in the reception area. Appointment Reminders and Other Contacts. We may disclose your PHI in the course of leaving phone messages and in providing you with appointment reminders via phone messages, postcards, letters, or emails. Individuals Involved in Your Care or Payment for Your Care.  We may disclose your PHI 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. 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 the patient representative the same way we would treat you with respect to your PHI. Disaster Relief. We may use or disclose your PHI to assist in disaster relief efforts. Coroners, Medical Examiners and Funeral Directors. We may use or disclose your PHI to coroners or medical examiners as necessary, for such purposes as identifying a deceased person or determining the cause of death. We may also use or disclose your PHI to funeral directors as necessary for their duties. Abuse or Neglect. We may use or disclose your PHI to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic abuse, or the victim of other crimes. Required by Law. We may use or disclose your PHI when we are required by law. Such circumstances include, but are not limited to, compliance with a court order, mandatory reporting due to serious or imminent threats to the public, mandatory reporting of child abuse or neglect, in response to government agency audits or investigations, and reporting disclosures to the Secretary or the Department of Health and Human Services as necessary for the purpose of investigating or determining our compliance with HIPAA. National Security. We may disclose to military authorities the PHI of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials PHI required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody, the PHI of an inmate or patient. Worker’s Compensation. We may disclose your PHI to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law. Research. We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information. Fundraising. We may contact you to provide you with the information about our sponsored activities, including fundraising programs, as permitted by applicable law. If you do not wish to receive such information from us, you may opt out of receiving the communications. Other Uses and Disclosures. Your authorization is required for disclosure of psychotherapy notes, use or disclosure of PHI for marketing, and for the sale of PHI. We will obtain your written authorization before using or disclosing your PHI for purposes other than those provided for in this notice (or as otherwise permitted or required by law). You may revoke an authorization in writing at any time.  Upon receipt of the written revocation, we will stop using or disclosing your PHI, except to the extent that we have already taken action in reliance on the authorization. Data Breach Notification Purposes. We may use or disclose your PHI to provide legally required notices of unauthorized access to or disclosure of your PHI.

YOUR HEALTH INFORMATION RIGHTS

Access. You have the right to look at or get copies of your PHI, with limited exceptions. You must make the request in writing and provide us a reasonable amount of time to respond, generally 30 days. We may charge a reasonable cost-based fee. Disclosure Accounting. You have the right to receive a list of instances, if any, in which we or our business associates or their sub-contractors disclosed your PHI for purposes other than treatment, payment, healthcare operations, and other permitted uses as described in this notice, for the last 3 years. 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 additional requests. Right to Request a Restriction. You have the right to request additional restrictions on our use or disclosure of your PHI by submitting a written request. Your written request may include what information you want to limit, whether you want to limit our use, disclosure or both, to whom you want the limits to apply. We are not required to agree to your request except in the case where the disclosure is to a health plan for purposes of carrying out payment or health care operations, and the information pertains solely to a health care item or service for which you, or a person on your behalf (other than the health plan), has paid our practice in full. Alternative Communications. You have the right to request, in writing that we communicate with you about your PHI by alternative means or at alternative locations. Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request. We will accommodate all reasonable requests. However, if we are unable to contact you using the ways or locations you have requested we may contact you using the information we have. Amendment. You have the right to request, in writing, that we amend your PHI. Your request must explain why the information should be amended.  We may deny your request under certain circumstances. Electronic. You may ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically on our web-site or by e-mail. Right to Notification of a Breach. You will receive notifications of breaches of your PHI as required by law. Questions and Complaints. If you have any concerns that we may have violated your privacy rights, or if you disagree with a decision we made about access to your PHI or in response to a request you made to amend or restrict the use of disclosure of your PHI, or to have us communicate with you by alternative means or at alternative locations, you may contact us in writing. In addition, you may file a complaint to:

  • Centralized Case Management Operations U.S. Department of Health and Human Services 200 Independence Avenue S.W. Room 509F HHH Building Washington D.C. 20201
  • OR visit hhs.gov/ocr/privacy/hipaa/complaints/.

We support your right to the privacy of your PHI.  We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.