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. THE PRIVACY OF YOUR MEDICAL INFORMATION IS
IMPORTANT TO US.
Our Legal Duty
We are required by applicable federal
and state laws to maintain the privacy of your protected health information. We are also required to give you
this notice about our privacy practices, our legal duties, and your rights concerning your protected health
information. We must follow the privacy practices that are described in this notice while it is in effect. This
notice takes effect April 14, 2003, 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 that 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 protected healthin formation that we maintain, including medical information we
created or received before we made the changes.
You may request a copy of our notice (or any
subsequent revised 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 Protected Health Information
We will use and
disclose your protected health information about you for treatment, payment, and health care operations.
Following are examples of the types of uses and disclosures of your protected health care information that may
occur. These examples are not meant to be exhaustive, but to describe the types of uses and disclosures that
maybe made by our office.
Treatment: We will use and disclose your protected health information to
provide, coordinate or manage your healthcare and any related services. This includes the coordination or
management of your health care with a third party. For example, we would disclose your protected health
information, as necessary, to a home health agency that provides care to you. We will also disclose protected
health information to other physicians who may be treating you. For example, your protected health information
may be provided to a physician to whom you have been referred to ensure that the physician has the necessary
information to diagnose or treat you.
In addition, we may disclose your protected health information
from time to time to another physician or health care provider (e.g., a specialist or laboratory)who, at the
request of your physician, becomes involved in your care by providing assistance with your health care diagnosis
or treatment to your physician.
Payment: Your protected health information 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: making
a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for
protected health necessity, and undertaking utilization review activities. For example, obtaining approval for a
hospital stay may require that your relevant protected health information be disclosed to the health plan to
obtain approval for the hospital admission.
Health Care Operations: We may use or disclose, as
needed, your protected health information in order to conduct certain business and operational activities. These
activities include, but are not limited to, quality assessment activities, employee review activities, training
of students, licensing, and conducting or arranging for other business activities.
For example, we
may use a sign-in sheet at the registration desk where you will be asked to sign your name. We may also call you
by name in the waiting room when your doctor is ready to see you. We may use or disclose your protected health
information, as necessary, to contact you by telephone or mail to remind you of your appointment.
We
will share your protected health information with third party "business associates" that perform various
activities (e.g., billing, transcription services) for the practice. Whenever an arrangement between our office
and a business associate involves the use or disclosure of your protected health information, we will have a
written contract that contains terms that will protect the privacy of your protected health
information.
We may use or disclose your protected health information, as necessary, to provide you
with information about treatment alternatives or other health-related benefits and services that may be of
interest to you. We may also use and disclose your protected health information for other marketing activities.
For example, your name and address may be used to send you a newsletter about our practice and the services we
offer. We may also send you information about products or services that we believe may be beneficial to you. You
may contact us to request that these materials not be sent to you.
Uses and Disclosures Based On Your
Written Authorization:Other uses and disclosures of your protected health information will be made only with
your authorization,unless otherwise permitted or required by law as described below.
You may give us
written authorization to use your protected 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. Without your written authorization, we
will not disclose your health care information except as described in this notice.
Others Involved in
Your Health 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 protected health information that directly relates to that person's
involvement in 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 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, general condition or
death.
Marketing: We may use your protected health information to contact you with information about
treatment alternatives that may be of interest to you. We may disclose your protected health information to a
business associate to assist us in these activities. Unless the information is provided to you by a general
newsletter or in person or is for products or services of nominal value, you may opt out of receiving further
such information by telling us using the contact information listed at the end of this
notice.
Research; Death; Organ Donation: We may use or disclose your protected health information for
research purposes in limited circumstances. We may disclose the protected health information of a deceased
person to a coroner, protected health examiner, funeral director or organ procurement organization for certain
purposes.
Public Health and Safety: We may disclose your protected health information to the extent
necessary to avert a serious and imminent threat to your health or safety, or the health or safety of others. We
may disclose your protected health information to a government agency authorized to oversee the health care
system or government programs or its contractors, and to public health authorities for public health
purposes.
Health Oversight: We may disclose protected health information to a health oversight agency
for activities authorized by law, such as audits, investigations and inspections. Oversight agencies seeking
this information include government agencies that oversee the health care system, government benefit programs,
other government regulatory programs and civil rights laws.
Abuse or Neglect: We may disclose your
protected health information to a public health authority that is authorized by law to receive reports of child
abuse or neglect. In addition, we may disclose your protected health information if we believe that you have
been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive
such information. In this case, the disclosure will be made consistent with the requirements of applicable
federal and state laws.
Food and Drug Administration: We may disclose your protected health
information 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; to enable product recalls; to make
repairs or replacements; or to conduct post marketing surveillance, as required.
Criminal Activity:
Consistent with applicable federal and state laws, we may disclose your protected health information, if we
believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health
or safety of a person or the public. We may also disclose protected health information if it is necessary for
law enforcement authorities to identify or apprehend an individual.
Required by Law: We may use or
disclose your protected health information when we are required to do so by law. For example, we must disclose
your protected health information to the U.S. Department of Health and Human Services upon request for purposes
of determining whether we are in compliance with federal privacy laws. We may disclose your protected health
information when authorized by workers' compensation or similar laws.
Process and Proceedings: We may
disclose your protected health information in response to a court or administrative order, subpoena, discovery
request or other lawful process,under certain circumstances. Under limited circumstances, such as a court order,
warrant or grand jury subpoena, we may disclose your protected health information to law enforcement
officials.
Law Enforcement: We may disclose limited information to a law enforcement official
concerning the protected health information of a suspect, fugitive, material witness, crime victim or missing
person. We may disclose the protected health information of an inmate or other person in lawful custody to a law
enforcement official or correctional institution under certain circumstances. We may disclose protected health
information where necessary to assist law enforcement officials to capture an individual who has admitted to
participation in a crime or has escaped from lawful custody.
Patient
Rights Access: You have the right to look at or get copies of your protected health information,
with limited exceptions. You must make a request in writing to the contact person listed herein to obtain access
to your protected health information. You may also request access by sending us a letter to the address at the
end of this notice. If you request copies, we will charge you $25.00 for each page or$10.00 per hour to locate
and copy your protected health information, and postage if you want the copies mailed to you. If you prefer, we
will prepare a summary or an explanation of your protected health information for a fee. Contact us using the
information listed at the end of this notice for a full explanation of our fee structure.
Accounting
of Disclosures: You have the right to receive a list of instances in which we or our business associates
disclosed your protected health information for purposes other than treatment, payment, health care operations
and certain other activities after April 14, 2003. After April14, 2009, the accounting will be provided for the
past six(6) years. We will provide you with the date on which we made the disclosure, the name of the person or
entity to whom we disclosed your protected health information, a description of the protected health information
we disclosed, the reason for the disclosure, and certain other information. If you request this list more than
once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional
requests. Contact us using the information listed at the end of this notice for a full explanation of our fee
structure.
Restriction Requests: You have the right to request that we place additional restrictions
on our use or disclosure of your protected health information. We are not required to agree to these additional
restrictions, but if we do, wewill abide by our agreement (except in an emergency). Any agreement we may make to
a request for additional restrictions must be in writing signed by a person authorized to make such an agreement
on our behalf. We will not be bound unless our agreement is so memorialized in writing.
Confidential
Communication: You have the right to request that we communicate with you in confidence about your protected
health information by alternative means or to an alternative location. You must make your request in writing. We
must accommodate your request if it is reasonable, specifies the alternative means or location,and continues to
permit us to bill and collect payment from you.
Amendment: You have the right to request that we
amend your protected health information. Your request must be in writing, and it must explain why the
information should be amended. We may deny your request if we did not create the information you want amended or
for certain other reasons. If we deny your request, we will provide you a written explanation. You may respond
with a statement of disagreement to be appended to the information you wanted amended. If we accept your request
to amend the information, we will make reasonable efforts to inform others, including people or entities you
name, of the amendment and to include the changes in any future disclosures of that
information.
Electronic Notice: If you receive this notice on our website or by electronic mail
(e-mail), you are entitled to receive this notice in written form. Please contact us using the information
listed at the end of this notice to obtain 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 using the information below. If you believe that we may have violated your privacy
rights, or you disagree with a decision we made about access to your protected health information or in response
to a request you made, you may complain to us using the contact information below. 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 protect the privacy of your protected 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
Name of
Contact Person:
Frinet Kasper, DDS
1203 Prince St
Alexandria, VA 22314
(703)
683-0800
MON8:00 am - 2:00 pm
TUE8:00 am - 5:00 pm
WED8:00 am - 2:00 pm
THU8:00 am - 5:00 pm
FRI8:00 am - 2:00 pm
SAT - SUNClosed
124 S. West Street, Suite 100, Alexandria, VA 22314
Email: info@oldtowndentistry.com
Book Now124 S. West Street, Suite 100,
Alexandria, VA, 22314
Phone: (703) 683-0800