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HUGO DENTAL
CARE 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 April 13, 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, or for additional copies of
this Notice, please contact us.
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 the
competence or qualifications of
healthcare professionals, evaluating
practitioner and provider performance,
conducting training programs,
accreditation, certification, licensing
or credentialing activities. Your
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 (including identifying
or locating) 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, then prior
to use or disclosure of your health
information, we will provide you with an
opportunity to object to such uses or
disclosures. In the event of your
incapacity or emergency circumstances,
we will disclose health information
based on a determination using our
professional judgment disclosing only
health information that is directly
relevant to the person's involvement in
your healthcare. We will also use our
professional judgment and our experience
with common practice to make reasonable
inferences of your best interest in
allowing a person to pick up filled
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 we are
required to do so by law. Abuse or
Neglect: We may disclose your health
information to appropriate authorities
if we reasonably believe that you are a
possible victim of abuse, neglect, or
domestic violence or the possible victim
of other crimes. We may disclose your
health information to the extent
necessary to avert a serious threat to
your health or safety or the health or
safety of others. National Security: We
may disclose to military authorities the
health information of Armed Forces
personnel under certain circumstances.
We may disclose to authorized federal
officials health information required
for lawful intelligence,
counterintelligence, and other national
security activities. We may disclose to
correctional institution or law
enforcement official having lawful
custody of protected health information
of inmate or patient under certain
circumstances. Appointment Reminders: We
may use or disclose your health
information to provide you with
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 that we provide copies
in a format other than photocopies. We
will use the format you request unless
we cannot practicably do so. You must
make a request in writing to obtain
access to your health information. You
may obtain a form to request access by
contacting our office. We will charge
you a reasonable cost-based fee for
expenses such as copies and staff time.
You may also request access by sending
us a letter to the address to our
address. If you request copies, we will
provide them to you for a fee, based an
current law. If you request an
alternative format, we will charge a
cost-based fee for providing your health
information in that format. If you
prefer, we will prepare a summary or an
explanation of your health information
for a fee. Disclosure Accounting: You
have the right to receive a list of
instances in which we or our business
associates disclosed your health
information for purposes, other than
treatment, payment, healthcare
operations and certain other activities,
for the last 6 years, but not before
April 14, 2003. If you request this
accounting more than once in a 12-month
period, we may charge you a reasonable,
cost-based fee for responding to these
additional requests. Restriction: You
have the right to request that we place
additional restrictions on our use or
disclosure of your health information.
We are not required to agree to these
additional restrictions, but if we do,
we will abide by our agreement (except
in an emergency). Alternative
Communication: You have the right to
request that we communicate with you
about your health information by
alternative means or to alternative
locations. You must make your request in
writing. Your request must specify the
alternative means or location, and
provide satisfactory explanation how
payments will be handled under the
alternative means or location you
request. Amendment: You have the right
to request that we amend your health
information. (Your request must be in
writing, and it must explain why the
information should be amended.) We may
deny your request under certain
circumstances. Electronic Notice: If you
receive this Notice on our Web site or
by electronic mail (e-mail), you are
entitled to receive this Notice in
written form.
QUESTIONS
AND COMPLAINTS If you want more
information about our privacy practices
or have questions or concerns, please
contact us. If you are concerned that we
may have violated your privacy rights,
or you disagree with a decision we made
about access to your health information
or in response to a request you made to
amend or restrict the use or disclosure
of your health information or to have us
communicate with you by alternative
means or at alternative locations, you
may complain to us using the contact
information listed at the end of this
Notice. You also may submit a written
complaint to the U.S. Department of
Health and Human Services. We will
provide you with the address to file
your complaint with the U.S. Department
of Health and Human Services upon
request. We support your right to the
privacy of your health information. We
will not retaliate in any way if you
choose to file a complaint with us or
with the U.S. Department of Health and
Human Services.
Contact
Officer:
Laurie Videen
5677 147th Street North
Hugo, MN 55038
651-429-1639
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