NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES:

• HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
• YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION
• HOW TO FILE A COMPLAINT CONCERNING A VIOLATION OF THE PRIVACY OR SECURITY OF YOUR HEALTH INFORMATION OR OF YOUR RIGHTS CONCERNING YOUR INFORMATION

YOU HAVE A RIGHT TO A COPY OF THIS NOTICE (IN PAPER OR ELECTRONIC FORM) AND TO DISCUSS IT WITH THE COMPLIANCE OFFICE AT THE NUMBER ABOVE OR IF YOU HAVE ANY QUESTIONS.

North Dallas Dental Health Responsibilities: 

This patient notice (“Notice”) describes our privacy practices and is prepared in accordance with the regulations governing the privacy of substance use disorder (“SUD”) treatment records found at 42 C.F.R. Part 2 (“Part 2”).

We reserve the right to change the terms of this Notice and to make the new notice provisions effective for records that it maintains.

If we revise this Notice, we will provide you with a copy by posting it on our website and at our locations. We will also provide a copy of the then-current Notice upon request.

While treating you, our employees and health care professionals follow this Notice. In addition, any person involved in your care, entities, sites, and locations may share medical information about you with each other for treatment, payment, or health care operations as described in this Notice.

We are required by law to maintain the privacy of your health information and to provide you with this Notice.

Our Duties to Safeguard your Protected Health Inforamtion:

Protected Health Information (“PHI”) is any information related to your health care that is shared or maintained in any manner. It includes your insurance information as well. This Notice applies to all PHI we generate. This Notice will tell you about the ways in which we may use and disclose your PHI. We also describe your rights and certain obligations we have regarding the use and disclosure of your PHI.

We are required by law to:

• maintain the privacy of your PHI and SUD Records (defined below);
• to provide you with this Notice
• follow the terms of the Notice that is currently in effect; and
• to notify you following a breach of any unsecured versions of SUD Records

How We  May Use and Disclose Medical Information About You – Treatment, Payment, and Health Care Operations.

Single Consent:  Except in an emergency or other special situations, you may provide a single consent for all future uses or disclosures of SUD Records for the purposes of treatment, payment, and/or health care operations pursuant to Part 2, so that we may use and disclose your PHI and/or SUD Records for the following purposes:

Healthcare Operations:  We use and disclose health information about you in order to perform administration, financial, legal, and quality improvement activities necessary to run a healthcare business. This may include quality assessment, staff training/credentialing, risk management, auditing and business planning.

Payment:  Activities to obtain reimbursement for services, including, billing, claims management, and coverage determination.  This may include submitting claims to insurance, eligibility checks, reviewing services for medical necessity, and coordinating benefits with third parties.

Treatment:  Providing, coordinating, or managing healthcare and related services by one or more providers, including consultation and referrals. This may include sending records to a specialist, reviewing ambulance notes or prescription verification.

As Permitted or Required by Law:  We may also use or disclose your health information without your written authorization for other reasons as permitted by law. We are permitted by law to share information, subject to certain requirements, in order to communicate information on health-related benefits or services that may be of interest to you, respond to a court order, or provide information to further public health activities (e.g., preventing the spread of disease) without your written authorization. We will also disclose health information about you when required by law, for example, in order to prevent serious harm to you or others.

Special Protections for Substance Use Disorder Records:  We are required by law to maintain the privacy and security of your SUD records and to notify you if a breach of your unsecured records occurs. If we intend to use or disclose your SUD records for fundraising purposes, we will provide you with a clear and conspicuous opportunity to opt out.

You may provide a single written consent that allows us to use and disclose your SUD records for all future treatment, payment, and health care operations. You have the right to revoke this consent at any time in writing, except to the extent that we have already acted in reliance on it. Information disclosed with your consent may be subject to redisclosure by the recipient; however, federal protections under 42 CFR Part 2 may still apply.

SUD records cannot be used in civil, criminal, administrative, or legislative proceedings against you without your written consent or a court order that meets strict federal requirements. You also have the right to request a restriction on how these records are shared (including the right to restrict disclosures if you pay for a service in full out-of-pocket) and to request an accounting of certain disclosures of your SUD records made over the past three years.

Pursuant to your Authorization:  When required by law, we will ask for your written authorization before using or disclosing your identifiable health information. If you choose to sign an authorization to disclose information, you can later revoke that authorization to cease any future uses or disclosures.

Right to Inspect and Copy:  In most cases, you have a right to inspect and copy the health information we maintain about you. If you request copies, we may charge you for each page. Your request to inspect or review your health information must be submitted in writing.

Right to an Accounting of Disclosures:  You have a right to receive a list of instances where we have disclosed health information about you for reasons other than treatment, payment, healthcare operations, or pursuant to your written authorization.

Right to Amend:  If you believe that information within our records is incorrect or missing, you have a right to request that we correct the incorrect or missing information.

Right to Request Restrictions:  You may request in writing that we not use or disclose information for treatment, payment, or other administrative purposes except when specifically authorized by you, when required by law, or in emergency circumstances. We will consider your request but are not legally obligated to agree to those restrictions.

Right to Request Confidential Communications: You have a right to receive confidential communications containing your health information. We are required to accommodate reasonable requests. For example, you may ask that we contact you at your place of employment or send communications regarding treatment to an alternate address.

Right to Receive a Paper Copy of this Notice:  If you have agreed to accept this notice electronically, you also have a right to obtain a paper copy of this notice from us upon request. To obtain a paper copy of this notice, please contact the contact officer listed at the bottom of this form.

Legal Information:  We are required by law to protect the privacy of your information, provide this notice about information practices, and follow the information practices that are described in this notice.

We may change our policies at any time. Before we make a significant change in our policies, we will provide you with a revised copy of this notice. You can also request a copy of our current notice at any time. For more information about our privacy practices, contact the contact officer listed at the bottom of this form.

Filing a Complaint:  If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact the person listed above. You also may send a written complaint to the U.S. Department of Health and Human Services; Office of Civil Rights. The person listed above can provide you with the appropriate address upon request or you may visit www.hhs.gov/ocr for further information.

Other Uses and Disclosures of Your PHI for which Authorization is Not Required.

Unless we have a consent signed by you, we may only disclose records related to you that are maintained now or in the future in its electronic health record including, but not limited to, SUD treatment records—except, subject to certain exceptions, SUD counseling notes—(“SUD Records”) in accordance with the limited circumstances permitted by Part 2 related to:

Disclosure to Relatives and Close Friends: We may disclose your PHI to a family member, other relative, a close personal friend or any other person if we: 1) obtain your agreement; 2) provide you with the opportunity to object to the disclosure; or, 3) we can reasonably infer that you do not object to the disclosure. Disclosure of SUD Records is subject to a stricter standard.

Incapacity or Emergency Circumstances: If you are not present, or the opportunity to agree or object to a use or disclosure cannot practicably be provided because of your incapacity or an emergency circumstance, we may exercise our professional judgment to determine whether a disclosure of PHI to relatives and/or close friends is in your best interest (disclosure of SUD Records is subject to a stricter standard). If we disclose information to a family member, other relative, or a close personal friend, we would disclose only information that is directly relevant to the person’s involvement with your health care.

Fundraising: We may contact you to request a contribution to support important activities. In connection with any fundraising, we may use and disclose your demographic information as well as the dates on which you received health care services, the department where you received your services, your treating physician, and outcome information related to your care. If you do not want to receive any fundraising requests, you may contact us.

Public Health Activities: We may disclose your PHI and/or SUD Records for public health activities under certain circumstances, including the following:

• Reporting births or deaths
• To prevent or control disease, injury, or disability
• To report child abuse or neglect
• To report reactions to medications or problems with products
• To notify individuals who may have been exposed to a disease or may be at risk for contracting a disease or condition
• Reporting PHI and/or SUD Records to your employer as required by laws addressing work-related illnesses and injuries or workplace medical surveillance

Victims of Abuse, Neglect or Domestic Violence: If we reasonably believe you are a victim of abuse, neglect or domestic violence, in accordance with current state law, we may disclose your PHI and/or SUD Records to a governmental authority, including a social service or protective services agency, authorized by law to receive reports of such abuse, neglect, or domestic violence.

Health Oversight Activities: We may disclose your PHI and/or SUD Records to a health oversight agency that is responsible to ensure compliance with rules of government health programs such as Medicare and Medicaid. These oversight activities include, for example, audits, investigations, inspections, and licensure.

Legal Proceedings and Law Enforcement: PHI and/or SUD Records, or testimony relaying the content of such records, will not be used or disclosed in any civil, administrative, criminal, or legislative proceedings against you unless based on specific written consent or a court order.  Records will only be used or disclosed based on a court order after notice and an opportunity to be heard is provided to you and/or the holder of the record required by Part 2 and 42 U.S.C. 290dd-2, which are a federal statute and set of regulations that, among other things, protect the privacy of SUD treatment records.  A court order authorizing use or disclosure must be accompanied by a subpoena or other similar legal mandate compelling disclosure before the record is used or disclosed.  

Deceased Persons: We may release PHI to a coroner or medical examiner authorized by law to receive such information.

Organ and Tissue Donation: We may disclose your PHI and/or SUD Records to organizations that obtain organs or tissues for banking and/or transplantation.

Public Safety: We may use or disclose your PHI and/or SUD Records to prevent or lessen a serious or imminent threat to the safety of a person or the public.

Research: Usually, we will ask for your permission or authorization before using your PHI and/or SUD Records for research purposes. However, we may use and disclose your PHI and/or SUD Records without your authorization if a qualified Institutional Review Board (“IRB”) has waived the authorization requirement. An IRB is a committee that oversees and approves research involving human subjects.

Disaster Relief Efforts: We may disclose your PHI and/or SUD Records to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status, and location.

Military, National Defense, and Security: We may release your PHI and/or SUD Records if required for military, national defense and security, and other special government functions.

Workers’ Compensation: We may release your PHI and/or SUD Records for workers compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.

Communications from Us: We may use or disclose your PHI and/or SUD Records to identify health-related services and products that may be beneficial to your health, such as notification of a new physician and/or additional products and services and then contact you about those products and services. If you do not wish to receive information of this type, please contact us..

As Required by Law: We may use and disclose your PHI and/or SUD Records when required to do so by any other laws not already referenced above.

Uses and Disclosures Requiring Your Specific Authorization.

Highly Confidential Information: Federal and State laws require special privacy protections for certain highly confidential information about you. This includes PHI that is: 1) maintained in psychotherapy notes or SUD counseling notes; 2) documentation related to mental health or developmental disabilities services; 3) drug and alcohol abuse, prevention, treatment and referral information; and, 4) information related to HIV status, testing and treatment as well as any information related to the treatment or diagnosis of sexually transmitted diseases. Generally, we must obtain your authorization to release this type of PHI. However, there are limited circumstances under the law when this type of PHI may be released without your consent. For example, certain sexually transmitted diseases must be reported to the Department of Health.

Other Uses or Disclosures Not Described in This Notice: Other uses and disclosures of PHI and/or SUD Records not covered by this Notice or permitted under the laws that apply to us will be made only with your written permission. Except as permitted under this Notice or as permitted by law, we will seek your written permission prior to using or sharing your information for marketing purposes or selling your information.  

Revocation:  Even after you give consent, you have the right to revoke that consent at any time in writing delivered to the address contained in this Notice or to the email address listed on this form. After we receive your written notice to revoke, it will terminate your earlier consent within five business days. Prior to such termination, we may have shared some or all of my information or otherwise taken action in reliance on your consent; neither the organization nor any of its representatives are liable for any release of information during such time.

Changes to This Notice.

We reserve the right to change this Notice. Revised Notices will be posted in appropriate locations and online at www.northdallasdentalhealth.com. We reserve the right to make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future. A copy of the current Notice is available upon request.

Complaints.

If you believe your privacy rights have been violated, you may file a complaint in writing to the contact officer listed below.

You may also wish to file a complaint with the Office for Civil Rights of the U. S. Department of Health and Human Services.   https://www.hhs.gov/ocr/complaints/index.html .We will not penalize you if you file a complaint.

Breach Notification.

We will notify you in the event of a breach (as defined by HIPAA) of your PHI and/or SUD Records.

Contact Officer: Christine Cohen

Telephone: 214-691-2404
Fax: 214-691-2228
E-mail: [email protected]

Address: 5465 Blair Road, Suite 200, Dallas, Texas 75231