Notice of Privacy Practices for Protected Health Information

Revised Date: 3-06-2019

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!

Who is covered by this notice:

This notice describes practices in the services provided for Orofacial-Myofunctional Therapy.

My Pledge Regarding Medical Information:

I understand that your health information is personal. I am committed to protecting this information. I create a record of care and services you/your child receives. I need this record to provide you with quality care and to comply with certain legal requirements.

This notice will tell you about the ways in which I may use and disclose your health information. I also describe your rights and certain obligations I have regarding the use and disclosure of health information.

I am required by law to:

· Make sure your health information is kept private

· Give you this notice of my legal duties and privacy practices

· Follow the terms of the notice that is currently in effect

How I may use and disclose your health information:

The following categories describe different ways I use and disclose medical information. I will explain what I mean and give some examples for each category. Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to use and disclose information will fall within one of the categories.

• For Treatment: I may use your health information to provide you with medical treatment or services. I may disclose this information to a medical and/or dental practitioner, an orofacial myologist or other practitioner involved in your treatment in my office.
• For Payment: I may use and disclose your health information so the treatment and service you receive at my office may be billed to an insurance company.
• For Health Care Operations: I may use and disclose your health information for health system operations. These uses and disclosers are necessary to run my facility, allow performance updates and make sure all of my patients receive quality care.
• Individuals involved in your care or payment for your care: I may release medical information about you to a family member or other designated person who is involved in your care, including transportation of you to my facility. I may also give information to someone who helps pay for your care. In addition, I may disclose medical information about you to an agency assisting in a disaster relief effort or other emergency situation so you may be safely transported, if necessary and so your family can be notified about your condition’s status, and location.
• As required by law: I will disclose medical information about you when required to do so by federal, state or local law.
• To avert a serious threat to health or safety: I may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.
• Public health risks: As required by law, I may disclose your health information to public health authorities for purposes related to: preventing or controlling disease, injury or disability; reporting medical device safety issues and adverse events to the Federal Food and Drug Administration’s MedWatch Program and reporting disease or infection exposure.
• Victim of abuse, neglect or domestic violence: I may disclose pertinent health information to government agencies authorized by law to receive reports of abuse, neglect or domestic violence if we believe you have been such a victim.
• Health oversight activities: I may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections and licensure.
• Law enforcement: I may release medical information to law enforcement official if required or permitted by law.
• Judicial and Administrative proceedings: I may disclose your health information in the course of an administrative or judicial proceeding, such as in a response to a court order.
• Specialized Government functions: I may release medical information about you to authorized federal officials for national security and intelligence, military or veterans activities require by law.

Uses of medical information that require authorization:

Disclosure of medical information not related to treatment, payment, or healthcare operations or not otherwise covered by this notice (e.g., under “Special Situations”) can be made only with your specific written authorization. You may revoke that authorization in writing any time. If you revoke your permission, I will no longer use or disclose medical information about you for the reasons covered by your written authorization. However, I will not be able to take back any disclosures I have already made with your prior permission.

Your Rights regarding medical information about you:

You have the following rights regarding medical information I maintain about you:

· Right to review and copy: You have the right to inspect and obtain a copy of medical information that may be used to make decisions about your care. Usually, this information includes medical and billing records, but does not include information compiled for use in or created in anticipation of a civil, criminal or administration action or proceeding.

· You must submit your request for your medical information in writing to the Privacy Officer. If you request a copy of the information, I will charge a fee of $35.00 for the costs of copying mailing or other supplies associated with your request.

· Right to amend: If you feel medial information I have about you is incorrect or incomplete, you may ask me to amend the information. You have the right to request an amendment for as long as the information is maintained.

· Submit your request to the Privacy Officer in writing and include a reason that supports your request.

· We may deny your request if you ask us to amend information that was provided to us by another provider or for information I believe is accurate and complete.

• Right to request restrictions: You have the right to request a restriction or limitation on the health information I use or disclose about you for treatment, payment or healthcare operations. You, also, have the right to request a limit on the payment of your care, like a family member or friend. For example, you can ask we not use or disclose information about your child’s prenatal history. If I do agree, I will comply with your request unless the information is needed to provide you emergency treatment.

· I am not required to agree to your request. Furthermore, I will not comply with any request, asking me to withhold information from insurance companies that are billed for services.

· You must make your request for any restrictions in writing to the Privacy Officer. In your request, you must tell me the following information:

o What information you want to limit

o Whether you want to limit my use, disclosure or both

o To whom you want the limits to apply (for example, to the person driving your child to therapy appointments)

• Right to request confidential communications: You have the right to request I communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that I only contact you at work or by mail.

· You muse make your request for confidential communications in writing to the Privacy Officer. I will not ask you the reason for your request. I will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

• Changes to this notice: I reserve the right to change this notice. I reserve the right to make the revised or changed notice effective for medical information I already have about you as well as any information I receive in the future. Current copies of this notice will be available in my office. The effective date of the notice will be posted on the first page, in the top right-hand corner.

• Complaints: If you believe your privacy rights have been violated, you may file a complaint by contacting the U.S. Office of Civil Rights, Washington, D.C. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

Website

If we maintain a website, providing information about our entity, this Notice will be on the website.