Purpose: This form, Notice of Privacy Practices, presents the
information that federal law requires us to give our patients regarding our
privacy practices
We must provide this Notice to each patient
beginning no later than the date of our first service delivery to the patient,
including service delivered electronically, after April 14, 2003. We must make
a good-faith attempt to obtain written acknowledgement of receipt of the Notice
from the patient. We must also have the Notice available at the office for
patients to request to take with them. We must post the Notice in our office in
a clear and prominent location where it is reasonable to expect any patients
seeking service from us to be able to read the Notice. Whenever the Notice is
revised, we must make the Notice available upon request on or after the
effective date of the revision in a manner consistent with the above
instructions. Thereafter, we must distribute the Notice to each new patient at
the time of service delivery and to any person requesting a Notice. We must
also post the revised Notice in our office as discussed above.
Thank you Dr. Timothy M. Hale
| {Timothy M. Hale D.D.S Katy Periodontics
Management, Inc.} |
| 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. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
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OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of
your health information. We are also required to give you this Notice about our
privacy practices, our legal duties, and your rights concerning your health
information. We must follow the privacy practices that are described in this
Notice while it is in effect. This Notice takes effect (04-01-03), 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. We
reserve the right to make the changes in our privacy practices and the new
terms of our Notice effective for all health information that we maintain,
including health information we created or received before we made the changes.
Before we make a significant change in our privacy practices, we will change
this Notice and make the new Notice available 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.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and
healthcare operations. For example:
Treatment: We may use or disclose your health information to a
physician or other healthcare provider providing treatment to you.
Payment: We may use and disclose your health information to
obtain payment for services we provide to you.
Healthcare Operations: We may use and disclose your health
information in connection with our healthcare operations. Healthcare operations
include quality assessment and improvement activities, reviewing the competence
or qualifications of healthcare professionals, evaluating practitioner and
provider performance, conducting training programs, accreditation,
certification, licensing or credentialing activities.
Your Authorization: In addition to our use of your health
information for treatment, payment or healthcare 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 an authorization, you may 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. Unless you give us a
written authorization, we cannot use or disclose your health information for
any reason except those described in this Notice.
To Your Family and Friends: We must disclose your health
information to you, as described in the Patient Rights section of this Notice.
We may disclose your health information to a family member, friend or other
person to the extent necessary to help with your healthcare or with payment for
your healthcare, but only if you agree that we may do so.
Persons Involved In Care: We may use or disclose health
information to notify, or assist in the notification of (including identifying
or locating) a family member, your personal representative or another person
responsible for your care, of your location, your general condition, or death.
If you are present, then prior to use or disclosure of your health information,
we will provide you with an opportunity to object to such uses or disclosures.
In the event of your incapacity or emergency circumstances, we will disclose
health information based on a determination using our professional judgment
disclosing only health information that is directly relevant to the person's
involvement in your healthcare. We will also use our professional judgment and
our experience with common practice to make reasonable inferences of your best
interest in allowing a person to pick up filled prescriptions, medical
supplies, x-rays, or other similar forms of health information.
Marketing Health-Related Services: We will not use your health
information for marketing communications without your written authorization.
Required by Law: We may use or disclose your health
information when we are required to do so by law.
Abuse or Neglect: We may disclose your health information to
appropriate authorities if we reasonably believe that you are a possible victim
of abuse, neglect, or domestic violence or the possible victim of other crimes.
We may disclose your health information to the extent necessary to avert a
serious threat to your health or safety or the health or safety of others.
National Security: We may disclose to military authorities the
health information of Armed Forces personnel under certain circumstances. We
may disclose to authorized federal officials health information required for
lawful intelligence, counterintelligence, and other national security
activities. We may disclose to correctional institution or law enforcement
official having lawful custody of protected health information of inmate or
patient under certain circumstances.
Appointment Reminders: We may use or disclose your health
information to provide you with appointment reminders (such as voicemail
messages, postcards, or letters).
PATIENT RIGHTS
Access: You have the right to look at or get copies of your
health information, with limited exceptions. You may request that we provide
copies in a format other than photocopies. We will use the format you request
unless we cannot practicably do so. (You must make a request in writing to
obtain access to your health information. You may obtain a form to request
access by using the contact information listed at the end of this Notice. We
will charge you a reasonable cost-based fee for expenses such as copies and
staff time. You may also request access by sending us a letter to the address
at the end of this Notice.
Disclosure Accounting: You have the right to receive a list of
instances in which we or our business associates disclosed your health
information for purposes, other than treatment, payment, healthcare operations
and certain other activities, for the last 6 years, but not before April 14,
2003. 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 these additional
requests.
Restriction: You have the right to request that we place
additional restrictions on our use or disclosure of your health information. We
are not required to agree to these additional restrictions, but if we do, we
will abide by our agreement (except in an emergency).
Alternative Communication: You have the right to request that
we communicate with you about your health information by alternative means or
to alternative locations. {You must make your request in writing.} Your request
must specify the alternative means or location, and provide satisfactory
explanation how payments will be handled under the alternative means or
location you request.
Amendment: You have the right to request that we amend your
health information. (Your request must be in writing, and it must explain why
the information should be amended.) We may deny your request under certain
circumstances.
Electronic Notice: If you receive this Notice on our Web site
or by electronic mail (e-mail), you are entitled to receive this Notice in
written form.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or
concerns, please contact us.
If you are concerned that we may have violated your privacy rights, or you
disagree with a decision we made about access to your health information or in
response to a request you made to amend or restrict the use or disclosure of
your health information or to have us communicate with you by alternative means
or at alternative locations, you may complain to us using the contact
information listed at the end of this Notice. You also may submit a written
complaint to the U.S. Department of Health and Human Services. We will provide
you with the address to file your complaint with the U.S. Department of Health
and Human Services upon request.
We support your right to the privacy of your 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.
Contact Officer: Rene' VanWave
Telephone: 281-392-6000
Fax: 281-392-6811
E-mail: katyperio@netzero.com
Address: 810 South Mason Rd Ste 325 Katy, TX 77450
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