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.
THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
Introduction
At Oglethorpe Family Dental, LLC (“Practice”) we are committed to treating and using protected health information about you responsibly. This Notice of Privacy Practices describes the personal information we collect, and how and when we use or disclose that information. It also describes your rights as they relate to your protected health information or PHI. This Notice is effective April 1, 2013, and applies to all PHI as defined by federal regulations.
Practice reserves the right to change the terms of this notice of privacy practices and to make the new notice provisions effective for all PHI we maintain. When we make a significant change in our privacy practices, we will post the new notice in the front entrance of our locations.
Understanding Your Health Record/Information
Each time you visit Practice, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:
• Basis for planning your care and treatment,
• Means of communication among the many health professionals who contribute to your care,
• Legal document describing the care you received,
• Means by which you or a third-party payer can verify that services billed were actually provided,
• A tool in educating health professionals,
• A source of data for medical research,
• A source of information for public health officials charged with improving the health of this state and the nation,
• A source of data for our planning and marketing, and
• A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.
Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.
Your Health Information Rights
Although your health record is the physical property of Practice, the information belongs to you. You have the right to:
• Obtain a paper copy of this notice of privacy practices upon request at this office.
• Copy and inspect the PHI we retain for you. All such requests for access must be made in writing. We are required to get back to you within 30 days after we get your letter. If we are unable give you your copy within 30 days, we may extend for an additional 30 days, provided that we let you know in writing of our delay. If requested and where possible, we will provide your copy in an electronic readable format. If we make a copy or summary of your PHI, we may charge you for copying, supplies, mailing or other costs.
• Request that the copy of your PHI be provided to another individual who you clearly identify in your signed, written request.
• Request an amendment or correction to your health record. All such requests must be made in writing.
▪ Receive an accounting of certain disclosures we have made, if any, of your PHI. To do this, please contact the Compliance & Audit Services Department at the number in this notice. This information will be provided to you within 60 days of receipt of your written request.
▪ Receive confidential communication of PHI.
▪ Request a restriction on certain uses and disclosures of your information. All such requests must be made in writing. We are not required to agree to a requested restriction but we must do what we say we will do.
▪ Request to receive communications of PHI by alternative means or at alternative locations.
▪ Request that we not disclose PHI to your health insurer for services for which you paid fort out of pocket, in-full.
Our Responsibilities
Practice is required by law to:
• Maintain the privacy of your PHI.
• Provide you with this notice of our legal duties and privacy practices with respect to your PHI.
• Abide by the terms of the notice currently in effect.
• Notify you if we are unable to agree to a requested restriction.
• Accommodate reasonable requests you may have to communicate your health information by alternative means or at alternative locations.
• Notify you following a breach of unsecured PHI
How We May Use and Disclose Medical Information About You
We can only use your PHI in certain ways. The law allows us to use you PHI without your permission for treatment, payment and operations.
Treatment: This generally means the delivery of health care and related services among health care providers, consultation between health care providers regarding your care or the referral of your treatment from one health care provider to another.
We will use and disclose your PHI to provide you with medical treatment or services.
We will record information in your record and use it to determine the most appropriate course of care.
We may provide PHI to other health care providers such as hospitals, consulting physicians and nurses, who are participating in your treatment.
We may provide PHI to pharmacists who are filling your prescriptions.
Payment: This involves the various activities of MHUP to obtain payment for their services and to fulfill your health plans’ coverage responsibilities, and to obtain or provide reimbursement for the provision of health care.
▪ Common payment activities are billing and collection activities.
▪ Determination of eligibility or coverage under a plan.
▪ Reviewing health care services for medical necessity, coverage, and justification of charges.
Operations: Certain administrative, financial, legal and quality improvement activities are necessary to run the business and to support the core functions of treatment and payment. Operational activities may include:
▪ Conducting or arranging for medical review.
▪ Legal and auditing services, including fraud and abuse detection and compliance programs.
▪ Competence review of members of the medical staff.
The law also allows us to use you PHI without your permission in the following ways:
Health Plans: We may also share PHI with other health care providers and health plans where you’ve been a patient in the past. We would only share this information to help them provide better care or to help them watch for fraud or abuse.
Notification: We may use or disclose information to notify or assist in notifying a family member, personal representative, or another person responsible for your care, your location, and general condition.
Communication with Family: Health professionals, using their best judgment, 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 or payment related to your care.
Research: We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information.
Funeral directors: We may disclose health information to funeral directors consistent with applicable law to carry out their duties.
Organ procurement organizations: Consistent with applicable law, we may disclose health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
Appointment Reminders and Other Items of Interest: We may also contact you for appointment reminders, or to tell you about or recommend possible treatment options, alternatives, or health-related benefits or services that may be of interest to you.
Fundraising: We may contact you as part of a fundraising effort. If you do not want to receive fundraising information please notify the Memorial Health Foundation at (912) 350-6370.
Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
Workers Compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.
Public Health: As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Law Enforcement: We may disclose health information for law enforcement purposes as required by law or in response to a valid subpoena.
Health Oversight Activities: We may disclose medical information to governmental, licensing, auditing, and accrediting agencies as authorized or required by law.
As Required by Law: We will disclose medical information about you when required to do so by federal or state law.
Other Uses and Disclosures: For any category of use or disclosure that is not described above or authorized by law, we must obtain your written authorization. This includes (i) most uses and disclosures of psychotherapy notes (if recorded by a covered entity); (ii) uses and disclosures of PHI for marketing purposes, including subsidized treatment communications; (iii) disclosures that constitute a sale of PHI. If you give us your written authorization, you may revoke (cancel) it at any time by submitting a written revocation to the office or location that originally received your authorization, or to the Privacy Officer at the address listed below. Your revocation will be effective except to the extent that we have already acted upon your authorization.
Substance Use Disorder. PLEASE BE AWARE THAT THE PRACTICE DOES NOT CREATE OR MAINTAIN ANY SUBSTANCE ABUSE DISORDER (SUD) RECORDS AT THIS PRACTICE, INCLUDING THOSE COVERED BY 42 C.F.R. Part 2. It is not a “PART 2 Program” as defined by 42 C.F.R. Part 2, and the practice’s receipt of any SUD records will be through the provision from your other medical providers. Federal law and regulations protect the confidentiality of SUD patient records, and these protections are in addition to the privacy protections provided under HIPAA. To the extent such records are inadvertently received by the practice and it becomes a “Lawful Holder” as defined by applicable law, we generally will not disclose any information identifying you as having a SUD, including for treatment, payment, or health care operations, unless you provide written consent, a court order is issued, or a valid medical emergency occurs and such disclosure is reasonably necessary. Further, in no event will we use or disclose any Part 2 Program record, or testimony that describes the information contained in your Part 2 Program record, in any civil, criminal, administrative, or legislative proceedings by any Federal, State, or local authority, against you, unless authorized by your consent or the order of a court after it provides you notice of the court order.
Additional Records. We also recognize that some information, such as HIV-related information, genetic information, any alcohol and/or substance use disorder treatment records, and mental health records may be entitled to special confidentiality protections under applicable state or federal law. Therefore, if we receive these records from another provider, we will handle them in accordance with all legal requirements. Practice does not provide psychotherapy services, however, any mental health records received as part of your medical history will not be disclosed without specific written authorization unless otherwise required by law.
For More Information or to Report a Problem
If you are concerned that your privacy may have been violated, or you disagree with a decision that we made about your health information, you may write or call our Privacy Officer listed below:
Oglethorpe Family Dental, LLC
Privacy Officer
615 W Oglethorpe Hwy
Hinesville, GA 31313
(912) 877-3070
If you believe your privacy rights have been violated, you can file a complaint with the Privacy Officer at the contact information above or with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either the Privacy Officer or the Office for Civil Rights. The address for the OCR is listed below:
Roosevelt Freeman, Regional Manager
Office of Civil Rights
U.S. Department of Health and Human Services
Atlanta Federal Center, Suite 3B70
61 Forsyth Street, S.W.
Atlanta, GA 30303-8909
(404) 562-7881
NOTICE OF NONDISCRIMINATION
Source: HHS Office for Civil Rights
Notice Informing Individuals About Nondiscrimination and Accessibility Requirements and Nondiscrimination Statement: Discrimination is Against the Law
Oglethorpe Family Dental, LLC complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Oglethorpe Family Dental, LLC does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.
Oglethorpe Family Dental, LLC:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
○ Qualified sign language interpreters
○ Written information in other formats (large print, audio, accessible electronic formats, other formats)
• Provides free language services to people whose primary language is not English, such as:
○ Qualified interpreters
○ Information written in other languages
If you need these services, contact Civil Rights Coordinator
If you believe that Oglethorpe Family Dental, LLC has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Oglethorpe Family Dental, LLC, Civil Rights Coordinator, 615 W. Oglethorpe Hwy, Hinesville, GA 31313, Phone number (912) 877-3070, Fax number (912) 877-3082. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-868-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
