Elliot Davis, D.D.S. — Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW HEALTH 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.
Our Legal Duty:
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect (04/15/2003), and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request. You may request a copy of our Notice at any time. For more information about our privacy practices, about the Science behind Tinnisense, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.
Uses and Disclosures of Health Information:
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:
Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you. Payment: We may use and disclose your health information to obtain payment for services we provide to you. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing practitioner competence, evaluating provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.
To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.
Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, prior to use or disclosure of your health information, we will provide you with an opportunity to object. In the event of your incapacity or emergency circumstances, we will disclose health information using professional judgment, disclosing only information relevant to the person’s involvement in your healthcare. We may allow a person to pick up prescriptions, medical supplies, x-rays, or other similar forms of health information.
Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization. Required by Law: We may use or disclose your health information when required to do so by law. Abuse or Neglect: We may disclose your information if we reasonably believe you are a victim of abuse, neglect, or domestic violence, or the victim of other crimes. National Security: We may disclose to military authorities the health information of Armed Forces personnel, or to authorized federal officials for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institutions or law enforcement officials under lawful custody circumstances. Appointment Reminders: We may use or disclose your health information to provide appointment reminders (such as voicemail messages, postcards, or letters).
Patient Rights:
Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request copies in a format other than photocopies. We will use the format you request unless not practicable. (You must make a request in writing to obtain access. You may obtain a form using the contact information at the end of this Notice. We will charge $0.75 per page, $30 per hour for staff time, plus postage if mailed. Summaries or explanations are available for a fee. Contact us for a full explanation of our fee structure.)
Disclosure Accounting: You have the right to receive a list of disclosures (other than for treatment, payment, healthcare operations, or certain authorized activities) for the past 6 years, but not before April 14, 2003. More than one request in 12 months may incur a reasonable fee.
Restriction: You have the right to request restrictions on our use or disclosure of your health information. We are not required to agree, but if we do, we abide by our agreement (except in emergencies).
Alternative Communication: You have the right to request that we communicate with you by alternative means or to alternative locations. Your request must be in writing and specify how payments will be handled.
Amendment: You have the right to request that we amend your health information. Requests must be in writing with explanation. We may deny under certain circumstances.
Electronic Notice: If you receive this Notice electronically (via our website or email), you are entitled to receive it in written form.
Questions and Complaints:
If you want more information about our privacy practices or have questions, please contact us. If you believe your privacy rights may have been violated, or disagree with a decision we made regarding your health information, you may complain to us using the contact information below. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address on request. We support your right to privacy and will not retaliate if you file a complaint.
Contact Officer: Privacy Officer
Telephone: (212) 645-9255
Web Site: www.TheManhattanDentist.com
E-mail: info@themanhattandentist.nyc
Address:
Elliot Davis, DDS
Privacy Officer
80 Fifth Avenue, Suite #1607
New York, NY 10011
Please Acknowledge Below:
I hereby acknowledge that I have been provided with a copy of the Notice of Privacy Practices. I hereby further acknowledge that I can print out this agreement, can be provided with a copy of this agreement from the office, or can receive an electronic copy via an email or text request. I hereby further acknowledge that while I have to press the button below, I am under no obligation to sign any agreement.
