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!
With your consent, the practice is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and healthcare operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services. This notice takes effect 1/15/03 and will remain in effect until we replace it. Find some examples below:
Treatment: We may use and disclose your protected health information in order to provide, coordinate or manage your care or related services. We may also disclose your protected health information to other dentists, physicians, and healthcare service providers who are now or become involved in taking care of you.
Payment: We may use or disclose your protected health information in order to obtain payment for services we provide to you.
Healthcare Operations: We may use or disclose your health information as needed in connection with our healthcare operations, such as contacting you regarding an appointment, our practice’s quality assessment and improvement, development of protocol and clinical guidelines, conducting training programs, credentialing, medical review, legal and insurance services.
The health record we maintain and billing records are the physical property of the practice. The information in it, however, belongs to you. You have a right to:
The practice is required to:
We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our Notice or by visiting our office and picking up a copy.
If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact Randi Widen.
Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to 1450 Busch Parkway, Buffalo Grove, IL 60089.
You may also file a complaint by mailing it or phoning the Secretary of Health and Human Services whose street address and phone number is 105 W. Adams Street, Chicago, Il 60603, 312-353-5160.
We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the practice.
We cannot, and will not, retaliate against you for filing a complaint with the Secretary.
Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.
Unless you object, we may disclose to a member of your family, a relative, close friend or other person you identify, your protected health information that directly relates to that person’s involvement in your healthcare. 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 judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location or general condition.
We may disclose to the FDA your protected health information relating to adverse events with respect to products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.
If you are seeking compensation through Workers’ Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers’ Compensation.
As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.
If you are an inmate of a correctional institution, we may disclose to the institution, or its agents, your protected health information necessary for your health and the health and safety of other individuals.
We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement.
Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.
We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order.
Other uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization and you may revoke the authorization as previously provided.