Your Information. Your Rights. Our Responsibilities.
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.
Your Rights
You have the right to:
Correct your paper or electronic medical record
Request confidential communication
Ask us to limit the information we share
Get a list of those with whom we’ve shared your information
Get a copy of this privacy notice
Choose someone to act for you
File a complaint if you believe your privacy rights have been violated
Your Choices
You have some choices in the way that we use and share information as we:
Provide disaster relief
Include you in a hospital directory
Provide mental health care
Market our services and sell your information
Raise funds
Our Uses and Disclosures
We may use and share your information as we:
•1 Run our organization •2 Bill for your services •3 Help with public health and safety issues •4 Do research •5 Comply with the law •6 Respond to organ and tissue donation requests •7 Work with a medical examiner or funeral director •8 Address workers’ compensation, law enforcement, and other government requests •9 Respond to lawsuits and legal actions |
Your Rights
When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.
Get an electronic or paper copy of your medical record
We will provide a copy or a summary of your health information, usually within 30 days of your request. We may charge a reasonable, cost-based fee.
Ask us to correct your medical record
We may say “no” to your request, but we’ll tell you why in writing within 60 days.
Request confidential communications
We will say “yes” to all reasonable requests.
Ask us to limit what we use or share
If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.
Get a list of those with whom we’ve shared information
We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
Get a copy of this privacy notice
You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.
Choose someone to act for you
We will make sure the person has this authority and can act for you before we take any action.
File a complaint if you feel your rights are violated
You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.
We will not retaliate against you for filing a complaint.
Your Choices
For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.
In these cases, you have both the right and choice to tell us to:
Share information in a disaster relief situation
Include your information in a hospital directory
If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
In these cases we never share your information unless you give us written permission:
Sale of your information
Most sharing of psychotherapy notes
In the case of fundraising:
Our Uses and Disclosures
How do we typically use or share your health information?
We typically use or share your health information in the following ways.
Treat you
We can use your health information and share it with other professionals who are treating you.
Run our organization
Example: We use health information about you to manage your treatment and services.
Bill for your services
Example: We give information about you to your health insurance plan so it will pay for your services.
How else can we use or share your health information?
We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.
Help with public health and safety issues
Helping with product recalls
Reporting adverse reactions to medications
Reporting suspected abuse, neglect, or domestic violence
Preventing or reducing a serious threat to anyone’s health or safety
Do research
Comply with the law
Respond to organ and tissue donation requests
Work with a medical examiner or funeral director
Address workers’ compensation, law enforcement, and other government requests
For law enforcement purposes or with a law enforcement official
With health oversight agencies for activities authorized by law
For special government functions such as military, national security, and presidential protective services
Respond to lawsuits and legal actions
Our Responsibilities
We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
We must follow the duties and privacy practices described in this notice and give you a copy of it.
We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.
For more information see:hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html.
Changes to the Terms of this Notice
We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.
Other Instructions for Notice
Questions about this should be directed to Dr. Van Timmeren at (616)538-1050 or info@vtfamilydentistry.com
Your Information will never be sold or used for marketing without your approval