This notification describes the privacy policies of this Orthodontic office. Above all, we strive to maintain confidentiality regarding your Orthodontic treatment information. There are times, however, where identifiable health information must be disclosed to specific entities such as your insurance carrier. Herein we describe how confidential Orthodontic and health information is used and disclosed, as well as how you can gain access to this confidential information.
Orthodontic offices are required by applicable federal and state laws to maintain confidentiality of Orthodontic health information generated for patients during the course of treatment. Through recent legislation, Orthodontic offices are now required to notify all patients about privacy practices, our legal duties concerning these pratices, and your rights concerning your health information. These office privacy policies take effect as of April 14, 2003 and will remain in effect until amended by this office.
Our patients are welcome to request copies of our office privacy policies at any time. Please keep this information on file with other documents from this office and check with our receptionists or office manager for any amended versions or changes.
Uses and Disclosures of Health Information
This office uses and discloses health information about you and /or family members for purposes of treatment, payment and Orthodontic practice operations. For example:
We may use or disclose your Orthodontic health information to Orthodontic colleagues, your physician or other health care providers rendering treatment.
We may use and disclose your Orthodontic information through regular mail, fax or electronic transmission to your Orthodontic insurance carrier to obtain payment for services rendered. Limited treatment information may also be disclosed to billing services which assist the office in preparing monthly billing statements.
Orthodontic Practice Operations
: We may use and disclose your health information in conjunction with our health care operations, which include quality assessment and improvement activities, reviewing the competence or qualifications of personnel who work in this office, evaluation performance, conducting training programs within the office, accreditation, certification, licensing or credentialing activities. Your health information may also be disclosed to our attorneys and consultants as necessary to respond to any type of investigation or legal action pertaining to the quality of treatment provided to you.
: In addition to our use of your health information for treatment, payment, or Orthodontic practice 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 such an authorization, you have the right to 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.
: You have the right to receive a list of instances in which this practice disclosed your Orthodontic information for purpose other than treatment, payment, Orthodontic practice operations and certain activities for the six month period starting April 15, 2003 and at any six month interval thereafter. If you request this accounting more than once in a twelve month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
: You have the right to request that we place additional restrictions on our use of disclosure of your Orthodontic health information. We reserve the right to discuss your request and we are not required to agree to your additional restrictions. If we agree to abide by your request, however, we may be exempted from this agreement in the event of an emergency.
: You have the right to request that we communicate with you about your Orthodontic health information by alternative means to alternative locations (fax or email, for example). You must make your request in writing, specifying the alternative means or location.
: If you first reviewed our privacy policies on our web site or by email, you are entitled to receive this notice in written form upon request.
Questions or Complaints
If you would like additional information about our privacy policies, or if you have questions or concerns, please contact our privacy officer listed below.
If you are concerned that we may have violated your privacy rights, if you disagree with a decision we made regarding access to your Orthodontic health information, if you question our response to a request you made with us to restrict the use or disclosure of your health information, then you may complain to us by contacting the privacy officer listed at the end of this notice. You may also correspond with the U.S. Department of Health and Human Services upon request.
We support your right to the privacy of your Orthodontic health information. 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.
Lori Johnson, Privacy Officer
3115 Lion Lane
Salt Lake City, UT 84121
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