NOTICE OF PRIVACY PRACTICES
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.
Under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), all medical records and
other individually identifiable protected health information (PHI) of which we have knowledge must be
kept confidential. All PHI used by us or disclosed by us is covered by this Act regardless of whether this
PHI is in electronic, oral, or paper form. Several new rights are granted to patients under this Act,
allowing control over how your PHI is used, how you can access it, and in some cases amend it.
We are required by law to maintain the privacy of your PHI and to provide you with notice of our legal
duties and privacy practices with respect to your PHI.
We may be assessed a penalty for any misuse or unauthorized disclosures of your personal health
information as regulated by HIPAA.
This Notice of Privacy Practices is effective on
We are bound to abide by the terms of this notice and reserve the right to revise this policy.
Should revisions be made, you will be notified in writing and a copy of the revised policy will be made.
available at your request.
Should any breach of unsecured PHI ever occur, we will notify the patient(s) involved within 10 business.
days of discovery of this breach.
You will be asked to sign a consent form authorizing us to use and disclose your personal health.
information only for the following purposes, as defined under the Act:
. Treatment means the provision, coordination, or management of health care and related services by
one or more healthcare providers, including the coordination of management of health care by a
healthcare provider with a third party; consultation between healthcare providers relating to a
patient; or the referral of a patient for health care from one healthcare provider to another. An
example of this would be a dentist referral to an orthodontist.
. Payment means obtaining reimbursement for the provision of health care, determinations of
eligibility of coverage; billing; claims management; collection activities; justification of charges; and
disclosure to consumer reporting agencies; protected health information relating to the collection of
reimbursements (only certain information may be disclosed). An example of this would be
submitting your bill for health care services to your insurance company
Documentation
All documentation related to the receipt and acknowledgment of the Notice of Privacy
Practice is maintained for a minimum of six (6) years.
Questions
Questions the Notice of Privacy Practices or its contents should be directed to the HIPAA
Privacy Officer. Questions about the distribution and acknowledgment process should
be directed to the practice supervisor or the HIPAA Privacy Officer.
Definition - Protected Health Information
Protected Health Information is defined as information that may identify a patient and
Includes:
. Demographic information that may identify a patient.
. Information related to the patient's past, present or future physical or mental
health and condition.
. Information related to health care services or payment for health care services.
Revising the NPP
Whenever Practice name privacy practices change or there is a change in the law or
HIPAA Rules that require a change to the Notice of Privacy Practices, Practice name
shall determine whether the practice must revise the Notice of Privacy Practices and, if
so, will revise the policy accordingly.
On or after the effective date of revisions to the Notice of Privacy Practices, then on or
after the effective date of the revision Practice name will:
1. Provide the new Notice of Privacy Practices to patients on their first appointment
and ask them to sign the acknowledgement.
2. Have a supply of paper copies of the new Notice of Privacy Practices available in the
practice and provide it to anyone who requests a copy.
3. Post the new Notice of Privacy Practices in a clear and prominent location in the
practice.
4. Post the new Notice of Privacy Practices on the practice's website.
5. Retain at least one copy of both the old and new Notice of Privacy Practices for at
least 6 years from the latter of the date when the document was created or the date
when the document was last in effect.