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!
Oral & Facial Surgeons of Arizona
5050 N. 40th Street, Suite 180
Phoenix, AZ 85018
1215 W. Rio Salado Pkwy, Suite 113
Tempe, AZ 85281
What This Is
This Notice describes the privacy practices of Oral & Facial Surgeons of Arizona
We are required by law to maintain the privacy of your medical and health information. Protected Health Information (PHI), and to provide you with this notice of our legal duties and privacy practices. We are also required to abide by the terms of this notice. We reserve the right to change those terms and any changes made will be effective for all medical and healthcare information we maintain. A copy of a revised notice will be available at our office or by contacting our privacy rights, or requests for additional information regarding your privacy to our Privacy Coordinator, or by writing Attention: Privacy Coordinator.
Uses and Disclosures of Protected Health Information. Your PHI may be used and disclosed by your doctor, our office staff, and others outside of our office that are involved in your care and treatment to pay your health care bills, to support the operation of the physician’s practice, and any other uses required by law.
- Treatment We will use and disclose PHI to provide, coordinate, or manage your health care and any related services, for example, to diagnose and treat your illness or injury. We may also disclose PHI to other providers involved in your treatment. In addition, we may contact you to provide appointment information about treatment alternatives or other health-related benefits and services that may be of interest to you.
- Payment We may use and disclose PHI to obtain payment for services we provide you or to confirm your coverage – an example would be sending a bill or authorization for your treatment to your insurance company, HMO, or other company that arranges or pays the cost of some, or all of your healthcare.
- Healthcare Operations We may use or disclose, as needed, your PHI to support the business activities of Oral & Facial Surgeons of Arizona. These activities may include, but are not limited to, internal administration, planning and various activities that improve the quality and cost-effectiveness of the care that we deliver to you. For example, we may disclose PHI to our office manager in order to resolve any complaints you may have and ensure that you have a pleasant visit with us.
We may also disclose PHI to your other healthcare providers when such PHI is required for them to treat you, or conduct certain health care operations, such as quality assessment and improvement activities, reviewing the quality and competence of health care professionals, or for health care fraud and abuse detection or compliance.
You have the right to review this “Notice” before signing the consent authorizing use and disclosure or your PHI for treatment, payment and health care purposes.
Requesting Restrictions. You may ask us to limit our use of disclosure or your protected health information. We are not required to agree to your request, but if we agree to it, we will abide by your request, except as required by law, in emergencies, or when the information is necessary to treat you. Your request must be: 1) In writing, 2) Describe the information you want restricted, 3) State if the restriction is to limit our use or disclosure, and 4) State to whom the restriction applies. If you wish to request restrictions, you may obtain a request form from our Privacy Coordinator and submit the completed form to the Privacy Coordinator/Office Manager
Right to Receive Confidential Communications. You may request, and we will accommodate, any reasonable written request for you to receive PHI by alternative means of communication or at alternative locations.
Right to Inspect and Copy Your Protected Health Information. You may request access to your medical record file and billing records maintained by us, in order to inspect and request copies of these records. All requests for access must be made in writing. Please obtain a record request form from our Privacy Coordinator and submit the completed form to the Privacy Coordinator. Under limited circumstances, we may deny you access to your records. If this happens, you may request a review of the denial.
Right to Amend Your Records. You may ask us to amend your health information if you believe that it is incorrect or incomplete. Your request must be in writing and must include a reason to support the amendment. Please obtain an amendment request form from our Privacy Coordinator and submit the completed form to the Privacy Coordinator. We will comply with your request unless we believe that the information that would be amended is accurate and complete or other special circumstances apply.
Right to Receive An Accounting of Disclosures. Upon written request, you may obtain a list of certain disclosures of PHI made by us during any period of time prior to the date of your request does not exceed six years and does not apply to disclosures that occurred prior to April 14, 2003.
Right to Obtain a Printed Copy of This Notice. You are entitled to receive a paper copy of our Privacy Practices by making a request at our office.
Right to File a Complaint. If you believe that we have violated your privacy rights, you may file a complaint directly with us using the contact information on the first page. You may also file a complaint with the Secretary of the Department of Health and Human Services.
We cannot, and will not, retaliate against you for filing a complaint with the Secretary.
Provide an Authorization for Other Uses and Disclosures. We will request your written authorization for uses and disclosures of your medical information that are not identified in this notice or permitted by law. You may revoke your authorization at any time in writing.
Permissible Uses and Disclosures Without Your Written Authorization:
Notification. Unless you object we may use or disclose your protected health information to notify or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.
Communication with Family. Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your care in payment for such care if you do not object or in an emergency.
Public Health Activities. Your health information may be disclosed to public health agencies, such as the FDA, required by law, charged with preventing and controlling disease, injury, or disability.
Victim of Abuse, Neglect, or Domestic Violence. If we reasonably believe you are a victim of abuse, neglect or domestic violence, we may disclose PHI to public authorities, authorized by law to receive reports of such abuse, neglect, or domestic violence.
Health Oversight Activities. We may disclose PHI to a health oversight agency that oversees the health care system and is charged with responsibility for ensuring compliance with the rules of government health programs such as Medicare or Medicaid.
Judicial and Administrative Proceedings. We may disclose PHI in the course of a judicial or administrative proceeding in response to a legal order other lawful process.
Law Enforcement. We may disclose PHI to the police or other law enforcement officials as required or permitted by law or in compliance with a court order or a grand jury or administrative subpoena.
Health or Safety. We may use or disclose PHI to prevent or lessen a serious and imminent threat to a person’s or the public’s health or safety.
Correctional Institutions.Workers’ Compensation. We may disclose PHI to comply with laws regarding workers’ compensation or other similar programs.
As Required by Law. We may use and disclose PHI when required to do so by any other law not already referred to in the preceding categories.
Website. If we maintain a website that provides information about our practice, this “Notice” will be on the website.
Effective Date and Duration of This Notice.
This Notice is effective on October 23, 2015
For more information about HIPPA or to file a complaint:
The U.S. Department of Health & Human Services
Office of Civil Rights
Washington D.C. 20201
Toll Free: 1-877-696-6775