your protected health information (PHI) to carry out treatment, payment or health care operations

and for other purposes that are permitted or required by law. It also describes your rights to

access and control your PHI. Each time you come to our office, a record of the visit is made,

which includes but is not limited to your health history, physical examination, test results,

diagnoses and treatment and any plans for future care and treatment. The information contained

in this record is referred to as your "protected health information (PHI)."

kept private, 2) provide you with this notice of our legal duties and privacy practices regarding

new notice will be effective for all PHI that we maintain at that time. Upon your request, we will

that a revised copy be sent to you in the mail, or ask for one at the time of your next

appointment.

A. Uses and Disclosures of PHI For Treatment, Payment and Healthcare Operations

healthcare operations.

Here are examples of the types of uses and disclosures of your PHI that our office is permitted to

make.

coordinate, or manage your health care and any related services. This includes the

coordination or management of your health care with a third party that has already

obtained your permission to have access to your PHI. For example, we would disclosure

your PHI, as necessary to the referring dentist that provides care to you.

In addition, we may disclose your PHI from time-to-time to another health care provider

(e.g., a specialist or laboratory) who, at the request of your dentist, becomes involved in

your care by providing assistance with your health care diagnosis or treatment.

2. Payment: Your PHI will be used, as-needed, to obtain payment for your health care

services. This may include certain activities that your health insurance plan may

undertake before it approves or pays for the health care services we recommend for you

such as: 1) making a determination of eligibility or coverage for insurance benefits, 2)

reviewing services provided to you for medical necessity, and 3) undertaking utilization

review activities (obtaining preauthorization). For example, a bill may be sent to you or

a third-party payor. The information on or accompanying the bill may include

information that identifies you and your diagnosis, plus any procedures performed or

supplies used.

PHI in order to support the business activities of our practice. These activities include,

but are not limited to, quality assessment activities, employee review activities, licensing,

training of health care personnel, and conducting or arranging for other business needs

including auditing functions and legal review.

4. Business Associates: There are some services provided in our practice through

contracts with third-party "business associates." These business associates perform

various activities (e.g. practice management consultants, computer networking

specialists) for our practice. Whenever an arrangement between our office and a business

associate involves the use or disclosure of your PHI, we will have a written contract

requiring that your PHI be kept private.

B. Uses and Disclosures of PHI Based Upon Your Written Authorization

disclosure your PHI without your written authorization. You may revoke a written

take back any disclosures we have already made with your permission.

for marketing and fundraising activities but only with your written authorization in some

circumstances. For example, if you sign a written authorization, your name and address

may be used to send you information about products or services that are provided by a

necessary for your treatment, care coordination, or alternative therapy options) without

your written authorization.

Authorization or Opportunity to Object

We may use and disclose your PHI in the following instances listed below. You have the

opportunity to agree or object to these uses or disclosures of all or part of your PHI. If you are

not present or able to agree or object to the use or disclosure of the PHI, then your dentist may,

using his/her professional judgement, determine whether the disclosure is in your best interest.

In this case, only the PHI that is relevant to your health care will be disclosed.

1. Facility Directories: Unless you object, we may include certain limited information

about you in a facility directory, such as your name, the location at which you are

receiving care, your condition (in general terms), and your religious affiliation. All of

this information, except religious affiliation, may be disclosed to people that ask for you

by name. For example, if you are hospitalized members of the clergy may be told your

religious affiliation.

2. Others Involved in Your Care: Unless you object, we may disclose to a member of

your family, a relative, a close friend or any other person you identify, your PHI that

directly relates to that person’s involvement in your health care or payment for your

health care. If you are unable to agree or object to such a disclosure, we may disclose

such information as necessary if we determine that it is in your best interest based on our

professional judgement. We may use or disclose PHI to notify or assist in notifying a

family member, legal representative or any other person that is responsible for your care,

of your location, current condition, or death.

3. Disaster Relief: We may use or disclose your PHI to an entity assisting in disaster

relief efforts so that your family can be notified about your condition, status, or location.

4. Emergencies: We may use or disclose your PHI in an emergency situation. If this

and has attempted to obtain your authorization but is unable to do so, he may still use or

disclose your PHI to treat you.

attempts to obtain authorization from you but is unable to do so due to substantial

communication barriers and he determines, using professional judgement, that you intend

to consent to use or disclosure under the circumstances.

Authorization or Opportunity to Object

We may use or disclose your PHI in the following situations without your authorization. These

Copyright: Healthcare Management Solutions, LLC

situations include:

1. Required by Law: We may use or disclose your PHI when required by federal, state or

local law. The use or disclosure will be made in compliance with the law and will be

limited to the relevant requirements of the law. You will be notified, as required by law,

of any such uses or disclosures.

your PHI to public health authorities for purposes such as: a) preventing or controlling

disease, injury, or disability, b) reporting disease or infection exposure to a person who

may have been exposed or may be at risk for contracting or spreading a disease or

condition, c) reporting child abuse or neglect, d) reporting if we believe that you have

been a victim of abuse or neglect, e) reporting, in certain circumstances, instances of

domestic violence, or f) reporting births and deaths. We may also disclose your PHI to

appropriate persons in order to prevent or lessen a serious and imminent threat to your

health or safety, or the health or safety of another person or the general public.

Disclosures will only be made to a person or agency permitted by law to collect or

receive the information. Disclosures will be made consistent with the requirements of

applicable federal and state laws.

3. Health Oversight: We may disclose PHI to a health oversight agency, authorized by

law and during the course of audits, investigations, inspections, licensure and other

proceedings required by government agencies to monitor the health care system,

government benefits programs, other government regulatory programs and civil rights

laws.

4. Food and Drug Administration: We may disclose your PHI to a person or company

required by the Food and Drug Administration to report adverse events, product defects

or problems, biologic product deviations, to track products, enable product recalls, make

repairs or replacements, or to conduct post marketing surveillance, as required.

5. Legal Proceedings: We may disclose PHI: 1) in the course of any judicial or

administrative proceeding, 2) in response to an order of a court or administrative tribunal

(to the extent such disclosure is expressly authorized), and 3) in certain conditions in

response to a subpoena, discovery request or other lawful process.

6. Law Enforcement: We may disclose PHI to law enforcement officials for purposes or

in situations, such as: 1) legal processes as otherwise required by law, 2) limited

information requests for identification and location purposes, 3) pertaining to victims of a

crime, 4) suspicion that death has occurred as a result of criminal conduct, 5) in the event

that a crime occurs on the premises of the practice, and 6) medical emergency (not on the

Practice’s premises) and it is likely that a crime has occurred.

7. Coroners, Funeral Directors, and Organ Donation: We may disclose PHI to a coroner

or medical examiner for identification purposes, determining cause of death or for the

coroner or medical examiner to perform other duties authorized by law. We may also

disclose PHI to a funeral director, as authorized by law, in order to permit the funeral

director to carry out their duties. We may disclose such information in reasonable

anticipation of death. PHI may be used and disclosed for organ, eye, tissue, or cadaver

donation purposes.

8. Research: We may disclose your PHI to researchers when their research has been

approved by an Institutional Review Board (IRB) that has reviewed the research proposal

and established protocols to ensure the privacy of your PHI. If a researcher has not

obtained the required waiver from an IRB, we will not disclose your PHI without your

written authorization, other than in a "limited data set" described below.

9. Military Activity and National Security: When the appropriate conditions apply, we

may use or disclose PHI of individuals who are Armed Forces personnel: 1) for activities

deemed necessary by appropriate military command authorities, or 2) to foreign military

authorities if you are a member of that foreign military service. We may also disclose

your PHI to authorized federal officials for conducting national security and intelligence

activities, including for the provision of protective services to the President or other

legally authorized individuals.

10. Workers’ Compensation: Your PHI may be disclosed by us as authorized to comply

with workers’ compensation laws and other similar legally-established programs.

11. Inmates: We may use or disclose your PHI if you are an inmate of a correctional

facility and your physician created or received your PHI in the course of providing care

to you.

with another practice or organization, your PHI will become the property of the new

owner.

13. Limited Data Set (LDS): For purposes of research, public health, or health care

operations, it may be necessary to use or disclose some of your PHI without written

authorization. In these situations, we may use your PHI to create a LDS in which certain

required direct identifiers (such as your name) have been removed. We will disclose the

assurances that this information will be used for limited purposes.

14. 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 to

investigate or determine our compliance with requirements of Section 164.500 (et. seq)

of the Health Insurance Portability and Accountability Act (HIPAA).

A. You have the right to inspect and copy your PHI.

This means you may inspect and obtain a copy of PHI about you that is contained in a designated

record set for as long as we maintain the PHI. A "designated record set" contains medical and

except for psychotherapy notes, information compiled in reasonable anticipation of, or use in, a

civil, criminal, or administrative action or proceeding, and PHI that is subject to law that

prohibits access to PHI. Depending on the circumstances, a decision to deny access may be

reviewed by a licensed health care professional chosen by us. The person conducting the review

will not be the person who denied your request. We will comply with the outcome of the review.

B. You have the right to request a restrictions or limitations of the use and disclosure of your

PHI.

the purposes of treatment, payment or healthcare operations. You may also request that any part

of your PHI not be disclosed to family members or friends who may be involved in your care or

state specifically 1) what information you want restricted, 2) whether you are requesting to

restrict use, disclosure or both, 3) to whom the restriction will apply, and 4) an expiration date.

not use or disclose your PHI in violation of that restriction unless it is needed to provide

emergency treatment. Please discuss any restriction you wish to request with the Privacy

We may terminate an agreed upon restriction without your consent. In that situation, the

restriction will only apply to PHI created or received before you were informed of the

termination of the restriction.

C. You have the right to request that you receive confidential communications from us by

alternative means or at an alternative location.

matters in a certain way or at a certain location. For example, you can ask that you only be

contacted at work or by mail. We will not request an explanation from you as to the basis for the

request, however we may want to know how payment will be handled or request an alternative

D. You have the right to request that your PHI be amended.

If you feel that PHI we have about you is not correct or is incomplete, you may ask us to amend

the information. You have the right to request an amendment for as long as we maintain your

PHI. Your request must be in writing and provide a reason to support your requested

amendment. Your request will be considered and changes will be made based on the medical

opinion of the dentist or physician originating the entry. In certain cases, your request may be

denied. If we deny your 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

amending you medical record.

E. You have the right to receive an accounting of certain disclosures we have made, if any, of

your PHI.

This right applies to disclosures for purposes other than treatment, payment or healthcare

made to you, for a facility directory (if applicable), to family members or friends involved in

your care or for notification purposes. You have the right to receive specific information

regarding these disclosures that occurred after April 14, 2003. The first list you request in a

twelve-month period will be free. For additional lists, we may charge you for the cost(s) of

providing the list(s). We will notify you of the cost(s) involved and you may chose to withdraw

or modify your request before any cost(s) are incurred. You may request this disclosure for any

time period up to a maximum time frame of six years. The right to receive this information is

subject to certain exceptions, restrictions and limitations.

You will not be penalized for filing a complaint. If you believe your privacy rights have been

Secretary of the Department of Health and Human Services.

807 Broad Street 433 Carriage Drive

Summersville, West Virginia 26651 Beckley, West Virginia 25801

Phone - 304-872-0300 or 1-888-872-5551 Phone: 304-256-3777 or 1-877-488-3331

Fax - 304-872-5999 Fax - 304-256-3779

In general, any information that is about your health, the care and treatment you receive, or the

payment for that care and treatment is considered protected health information (PHI) and

uses and disclosures.

This Notice explains how my protected health information is used and/or disclosed for purposes

of treatment, payment and health care operations.

___________________________________ __________________________

Signature of Patient or Legal Representative Date

_____________________________________ __________________________

Print Name of Patient or Legal Representative Legal Representative’s Authority

FOR Lewis D. Gilbert, DDS USE ONLY:

__________________.

The acknowledgment was not obtained for the following reason(s): _________________

_______________________________________________________________________

_______________________________________________________________________

Signature of Privacy Officer: __________________________ Date: ________________

 

Copyright: Healthcare Management Solutions, LLC   April, 2003