Notice of Privacy
Practices
Grout Family Dentistry, P.C. -
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. You
have the right to obtain a paper copy of this Notice upon
request.
PATIENT HEALTH INFORMATION: Under
federal law, your patient health information is protected and
confidential. Patient health information includes information
about your symptoms, test results, diagnosis, treatment, and
related medical information. Your health information also
includes payment, billing and insurance information.
HOW WE USE YOUR PATIENT HEALTH
INFORMATION: We use health information about you for treatment,
to obtain payment and for health care operations, including
administrative purposes and evaluation of the quality of care
that you receive. Under some circumstances, we may be required
to use or disclose the information even without your
permission.
EXAMPLES OF TREATMENT, PAYMENT,
AND HEALTH CARE OPERATIONS:
Treatment: We will use and
disclose your health information to provide you with medical
treatment or services. For example, nurses, physicians and
other members of your treatment team will record information in
your record and use it to determine the most appropriate course
of care. We may also disclose the information to other health
care providers who are participating in your treatment, to
pharmacists who are filling your prescriptions, and to family
members who are helping with your care.
Payment: We will use and disclose
your health information for payment purposes. For example, we
may need to obtain authorization from your insurance company
before providing certain types of treatment. We will submit
bills and maintain records of payments from your health
plan.
Health Care Operations: We will
use and disclose your heath information to conduct our standard
internal operations, including proper administration of
records, evaluation of the quality of treatment, and to assess
the care and outcomes of your case and others like
it.
SPECIAL USES: We may use your
information to contact you with appointment reminders. We may
also contact you to provide information about treatment
alternatives or other health-related benefits and services that
may be of interest to you.
OTHER USES AND DISCLOSURES: We may
use or disclose identifiable health information about you for
other reasons, even without your consent. Subject
to certain requirements, we are
permitted to give out health information without your
permission for the following purposes: REQUIRED BY LAW: We may
be required by law to report gunshot wounds, suspected abuse or
neglect or similar injuries and events. RESEARCH: We may use or
disclose information
for approved medical
research.
Public Health Activities: As
required by law, we may disclose vital statistics, diseases,
information related to recalls of dangerous products, and
similar information
to public health
authorities.
Health Oversight: We may be
required to disclose information to assist in investigations an
audits, eligibility for government programs and similar
activities.
Judicial And Administrative
Proceedings: We may disclose information in response to an
appropriate subpoena or court order.
Law Enforcement Purposes: Subject
to certain restrictions, we may disclose information required
by law enforcement officials.
Deaths: We may report information
regarding deaths to coroners, medical examiners, funeral
directors and organ donation agencies.
Serious Threat To Health Or
Safety: We may use and disclose information when necessary to
prevent a serious threat to your health and safety or the
health and safety of the public or another person.
Military And Special Government
Functions: If you are a member or the armed forces, we may
release information as required by military command
authorities.
We may also disclose information
to correction institutions or for national security
purposes.
Workers Compensation: We may
release information about you for workers compensation or
similar programs providing benefits for work-related injuries
or illness. In any other situation, we will ask for your
written authorization before using or disclosing any
identifiable health information about you. If you choose to
sign an authorization to disclose information, you can later
revoke that authorization to stop any future uses and
disclosures.
Individual Rights: You have the
following rights with regard to your health information. Pease
contact the person listed below to obtain the appropriate form
for exercising these rights.
Request Restrictions: You may
request restrictions on certain uses and disclosures of your
health information. We are not required to agree to such
restrictions,
but if we do agree, we must abide
by those restrictions.
Confidential Communications: You
may ask us to communicate with you confidentially by, for
example, sending notices to a special address or not using
postcards to remind you of appointments.
Inspect And Obtain Copies: In most
cases, you have the right to look at or get a copy of your
health information. There may be a small charge for the
copies.
Amend Information: If you believe
that information in your record is incorrect, or if important
information is missing you have the right to request that we
correct the existing information or add the missing
information.
Accounting Disclosures: You may
request a list of instances where we have disclosed health
information about you for reasons other than treatment, payment
or health care operations.
OUR LEGAL DUTY: We are required by
law to protect and maintain the privacy of your health
information, to provide this NOTICE about our legal duties and
privacy practices regarding protected health information, and
to abide by the terms of the Notice currently in
effect.
CHANGES IN PRIVACY PRACTICES: We
may change our polices at any time. Before we make a
significant change in our policies, we will change our Notice
and post the new Notice in the waiting area and each
examination room. You can also request a copy of our Notice at
any time. For more information about our privacy practices,
contact the person listed below.
COMPLAINTS: If you are concerned
that we have violated your privacy rights or if you disagree
with a decision we made about your records, you may
contact
the person listed below. You also
may send a written complaint to the US Dept. of Health and
Human Services. The person listed below will provide you with
the appropriate address upon request. You will not be penalize
in any way for filing a complaint.
CONTACT PERSON: If you have
questions, requests, or complaints please contact:
Ronald W. Grout, DDS
Jeffrey B. Grout, DDS
Grout Family Dentistry,
P.C.
8 West Dry Creek Circle, Suite
101
Littleton, CO 80120
303.730.1222
Effective Date: April 14,
2003
I,____________________________________________,
hereby acknowledge receipt of the Notice of
Privacy Practices given to
me
Signed:________________________________________
Date:__________________________________
If not signed, reason why
acknowledgement was not obtained:
_______________________________________________
Staff Witness seeking
acknowledgement___________________________
Date_________________
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