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HIPAA PRIVACY POLICY NOTICE
For Gregory Sy, DDS & Associates, Inc.
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.

USES AND DISCLOSURES
Our office must provide you, the patient, a description and at least one example of the types of uses and disclosures that our office is permitted to make for the purposes of treatment, payment and health-care operations (all uses and disclosures, by the way, that are permitted by the law without authorization by the patient).

Treatment—Our office will use and disclose your protected health information (PHI) for purposes of treatment, meaning the provision, coordination and management of your health care and related services. For instance, we will use and disclose your health information to coordinate benefits with a third-party payer, or for consultation between our office and a specialist if required for your care.

Payment—Our office will use and disclose the minimum necessary amount of your PHI to obtain payment for services rendered. For example, our office may share your treatment plan with your insurer to determine the coverage allowed by your benefits plan.

Health-care operations—Our office will use and disclose the minimum necessary amount of your PHI for health-care operations, such as business planning and development that involves conducting cost-management and planning-related analyses related to managing and operating the entity, including formulary development and administration, development or improvement of methods of payment or coverage policies. This section of our policy also must describe other purposes for which our office is permitted or required to use or disclose your PHI without your written authorization. No examples of each of the following instances is required in this notice.

Required by law—Our office may use and disclose your PHI only to the extent that such use is required by law.

Public health activities—Our office may use and disclose the minimum necessary amount of your PHI to appropriate public health authorities for reasons such as, but not limited to, preventing or controlling disease, injury or child abuse and neglect.

Reporting abuse, neglect or domestic violence—Our office may use and disclose the minimum necessary amount of your personal health information to the extent necessary to inform the appropriate government authority if we reasonably believe you to be a victim of abuse, neglect or domestic violence.

Health oversight activities—Our office may use and disclose the minimum
necessary amount of your PHI to a health oversight agency for oversight activities authorized by law, such as for, but not limited to, audits.

Judicial and administrative proceedings—Our office may use and disclose the minimum necessary amount of your PHI in the course of any judicial or administrative proceeding if required by law to do so. Law enforcement agencies—Our office may use or disclose the minimum necessary amount of your PHI to a law enforcement agency if required by law to do so.Deceased patients—Our office may use or disclose the minimum necessary amount of your PHI to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death or another matter authorized by law, or to funeral directors to carry out their duties with respect to the deceased individual.

Research purposes—Our office may use and disclose the minimum necessary amount of your PHI for research purposes without your written authorization only if we have obtained one of the following: documented institutional review board or privacy board approval, either written or verbal representations that the information is to be used only to prepare a research protocol, either written or verbal representations that the information being sought is solely for research on the PHI of decedents, or a limited data use agreement.

Specialized government functions—If you are a member of the Armed Forces, our office will use and disclose the minimum necessary amount of your PHI for military and veterans activities. Our office also will use and disclose the minimum necessary amount of your PHI for national security and intelligence activities, for protective services for the U.S. president and others. Our office also will use and disclose the minimum necessary amount of your PHI to a correctional institution or law enforcement agency if you are an inmate and that agency or institution indicates the information is necessary.

Safety—Our office may use or disclose the minimum necessary amount of your PHI if we believe doing so is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and other specific circumstances.

Workers' compensation proceedings—Our office may use or disclose the minimum necessary amount of your PHI as authorized by and to the extent necessary to comply with laws related to workers' compensation or similar programs.

Patient directory—Except when an objection is expressed by you, our officemay use or disclose the minimum necessary amount of your PHI to maintain a directory of patients in the office. Said information includes your name, your location in the office, your condition described in general terms. We will inform you in advance of any such need and give you an opportunity to object, except in cases of emergencies when we must exercise professional judgment to determine whether use and disclosure of this information is in your best interest.

Friend, family and personal representatives—Our office will use and disclose the minimum necessary amount of your PHI that is directly relevant to the involvement of a family member, other relative, a close personal friend or someone else identified by you. Involvement could be in relation to care or payment for services. Our office also will use and disclose the minimum necessary amount of your PHI regarding your location, general condition or death to a family member, a personal representative of yours or another person responsible for the your care. Such uses and disclosures will be made only with your permission if you are present, unless you are incapacitated or there is an emergency circumstance where our office must exercise professional judgment.

Federal investigation—Our office may use and disclose the minimum necessary amount of your PHI for an investigation by the U.S. Department of Health and Human Services Secretary to determine if our office is in compliance with the HIPAA privacy regulation that requires us to protect your individually identifiable health information.

Business associates—Our office may disclose the minimum necessary amount of your PHI to a business associate or allow the business associate to create or receive your PHI on our behalf only if the business associate has agreed in writing to appropriately safeguard
the information.

Appointment reminders—Our office may use and disclose the minimum necessary amount of your PHI when contacting you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest
to you.

Marketing—Our office will obtain written authorization from you if we would like to use your PHI for marketing purposes, except for face-to-face communications or a promotional gift of nominal value provided to you while visiting this office. This office will inform you via the written authorization form if this office is to receive remuneration in connection with any marketing purpose. You have the right to revoke any authorizations as long as you do so
in writing.

General authorization statement—For any other purposes not stated in this notice, our office will not use or disclose your PHI without your prior written authorization.

PATIENT'S RIGHTS
The patient—You have the right to inspect or obtain a copy of your PHI from our office. Our office requires you to submit such requests in writing to our privacy director. Our office must act on your request no later than 30 days after receipt of your request, unless the PHI requested is not maintained or accessible to our office on site. In the latter case, our office must respond to your request within 60 days of your request, and we must inform you of any such delay in writing within the initial 30-day timeframe. If further delays are required, our office must may extend the time needed to respond to your request an additional 30 days provided that our office informs you in writing of the reasons for the delay and offers a date by which our office will respond to your request. Our office will provide you with access to your PHI to inspect or to obtain a copy, or both, in the form requested, if reasonable. If you agree to receive a summary of your PHI, our office will supply you with access to the summary. Our office will charge you a cost-based fee for the provision of any copies provided to you.

Denial of access appeals—If our office denies your request for access to your PHI in whole or in part, we must provide you with access to any other PHI for which access is not denied. For the information that is denied, our office must inform you in writing of this denial within 30 days of the original request, and the statement must provide the basis for the denial. Reasons for denial may include the following circumstances: The doctor has determined, using his professional judgment, that access to the information is reasonably likely to endanger the life or physical safety of you or another person; the information requested makes reference to another person (unless the other person is a health-care provider) and the doctor has determined, using his professional judgment, that granting your request is reasonably likely to cause substantial harm to this other person; and when the request for information is made by your personal representative and the doctor, using his professional judgment, has decided that the provision of the information to the personal representative is reasonably likely to cause substantial harm to you or another person. If access to your PHI is denied for these reasons, you have the right to have the denial reviewed by Dr. Gregory Sy, who has agreed to serve in this capacity for our office. Dr. Gregory Sy cannot be involved in the original decision to deny access to your PHI. Our office will inform you in writing as to the decision by Dr. Gregory Sy within a reasonable period of time.

Restrictions—You have the right to request restrictions on certain uses and
disclosures of your PHI, though our office is not required to grant such requests.

Confidential communications—You have the right to request, and our office must accommodate reasonable requests to receive confidential communications of PHI from our office by alternative means or at alternative locations.

Accounting of disclosures—You have the right to receive an accounting of disclosures of your PHI made by our office for the six years prior to the date on which the accounting is requested. The following disclosures are exempted from this accounting: Disclosures to carry out treatment, payment and health-care operations; to you, the patient; for incidental uses or disclosures; disclosures made according to your written authorization; for the office patient directory; for national security; for correctional institutions; for a limited data set; or any disclosure that occurred prior to April 14, 2003. Our office will provide you with a written accounting that includes the disclosures required to be listed, such as those to business associates of our office. This accounting will include the date of disclosure, the name of the entity or person who received the PHI.

Electronic notice—You have the right to receive a paper form of this notice of privacy policies from our office upon request if this notice was received electronically.

Right to amend—You have the right to request our office amend your PHI. Our office, however, may deny such a request if we determine that the PHI was not created by our office, is not part of the designated record set, the information is not available for access to you, or the current information is accurate and complete. Amendment requests must be made in writing to our privacy director. Our office must act on such requests within 60 days of receipt of such requests. If we deny your request, we will inform you in writing within 60 days, indicating one of the reasons listed previously as the basis for the denial. If you do not submit a statement of disagreement, you may request that our office provide your request for amendment and the denial with any future disclosures of your PHI that is the subject of the amendment. If you submit a statement of disagreement (limited to 500 words), our office may prepare a written rebuttal to your statement. We will provide you with a copy of the rebuttal.

DENTAL OFFICE DUTIES
Our office is 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 PHI. Our office is required to abide by the terms of the notice currently in effect. Our office reserves the right to change the terms of this notice and to make the new notice provisions effective for all PHI that we maintain.

COMPLAINTS
Patients may file a complaint with our office and with the U.S. Department of Health and Human Services Secretary if they believe their privacy rights have been violated. Complaints must be filed within 180 days of when you knew or should have known that the alleged violation occurred. To do so, please request a complaint form from our privacy director. Please be assured, patients who file complaints will not be retaliated against for doing so.

CONTACT
For more information about our office's privacy policies, contact:
Privacy Director: Gregory Sy, DDS
Telephone: 440-282-9550

EFFECTIVE DATE
This notice for our practice is effective as of January 01, 1996


© 2011 Gregory Sy DDS & Associates, Inc. All rights reserved. 1755 Cooper Foster Park Rd, Amherst, OH 44001 P: 440.282.9550 F: 440.282.8215 Email: grsdds2006@yahoo.com