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.
Effective date: [TO BE INSERTED BY THE PRACTICE BEFORE PUBLICATION]
This notice applies to Family Dental Care Missouri, 1010 Walnut St, Suite 280, Kansas City, MO 64106, and describes our practices regarding your protected health information (PHI) and those of any staff, students and volunteers working under our supervision.
Treatment. We use your health information to provide dental care, and may disclose it to other health professionals involved in your care, for example another health professional involved in your care, or your physician when a medical question affects your dental treatment.
Payment. We may use and disclose your health information to bill and collect payment: filing claims with your dental insurance plan, confirming coverage, and processing payments, including through our billing service acting under a business associate agreement.
Health care operations. We may use your health information to run the practice: quality review, training, scheduling, appointment reminders by phone, text or email, and telling you about treatment options or services we offer. You may ask us to use a specific phone number or address for reminders.
Business associates. Some services, such as billing and information technology, are provided through contractors who must, by written agreement, safeguard your information as we do.
As required or permitted by law. We may disclose health information when law requires or permits it, including public health reporting, health oversight activities, responses to lawful subpoenas or court orders, to avert a serious threat to health or safety, and to workers' compensation programs to the extent authorized.
Family and others involved in your care. Unless you object, we may share information relevant to their involvement with a family member or friend involved in your care or in payment for it, and we may use professional judgment in emergencies.
Uses requiring your written authorization. Most uses of psychotherapy notes (which dental practices rarely hold), uses for marketing purposes, and any sale of your information require your written authorization, which you may revoke in writing at any time except to the extent we have already relied on it.
You have the right to: inspect and receive a copy of your dental record, including an electronic copy where we hold it electronically; request corrections to your record; receive a list of certain disclosures we have made; request restrictions on certain uses and disclosures, including the right to restrict disclosure to your health plan for services you have paid for in full out of pocket, which we must honor; request confidential communications by alternative means or locations; receive a paper copy of this notice on request even if you agreed to electronic notice; and be notified if a breach of your unsecured health information occurs.
We are required by law to maintain the privacy and security of your protected health information, to provide you this notice of our legal duties and privacy practices, to abide by the terms of the notice currently in effect, and to notify affected individuals following a breach of unsecured PHI. We reserve the right to change this notice and to make the revised notice effective for information we already hold; the current notice will always be posted in the office and on this page.
To exercise any right above, or to ask questions about this notice, contact our Privacy Officer: [PRIVACY OFFICER NAME - TO BE INSERTED BY THE PRACTICE BEFORE PUBLICATION], Family Dental Care Missouri, 1010 Walnut St, Suite 280, Kansas City, MO 64106, (816) 439-7715.
If you believe your privacy rights have been violated, you may file a complaint with us at the address above or with the Secretary of the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you for filing a complaint.