Effective Date: April 1, 2018
Purpose of this Notice
This notice describes how your medical information may be used and disclosed and how you can get access to that information. Please review this Notice carefully.
Life Dental Group, LLC, a Mississippi limited liability company, together with our affiliated covered entities (collectively, “we,” “our,” “us”), are required by law to maintain the privacy of your protected health information. Protected health information (“PHI”) means any information that is created or received by us that identifies you and that relates to your past, present, or future physical or mental health, or condition, treatment, or payment for your health care. We are also required by law to notify you (1) of our legal duties and privacy practices with respect to PHI and (2) in the event of a breach of your PHI. Therefore, we have adopted this Notice of Privacy Practices (“Notice”), which relates to those duties.
This Notice applies to PHI created, maintained, used or disclosed in records related to the care and services that you receive at any of our clinics. We maintain your PHI in records that are kept confidential, as required by law. However, we must use and disclose your PHI to the extent necessary to provide you with quality health care. To do this, we must share your PHI with our affiliates, as necessary, and with others, as appropriate, for treatment, payment, and health care operations.
How We May Use and Disclose Your PHI
Applicable law generally permits use and disclosure of your PHI without your permission for purposes of health care treatment, payment activities, and health care operations. These uses and disclosures are more fully described below. Please note that this Notice does not list every possible use or disclosure but instead gives examples of some common uses and disclosures.
- Treatment. We may use or disclose your PHI to facilitate medical treatment or services by providers. We may disclose your PHI to health care providers who are involved in taking care of you. For example, we might disclose your PHI with dentists who are treating you.
- Payment. We may use and disclose your PHI as requested by your health plan, insurer, or other third-party payor to obtain payment for treatments or services we provided you. We may also tell your health plan, insurer or other third-party payor about a treatment or service you might receive in order to obtain prior approval or to determine whether your health plan, insurer or other third-party payor will cover the treatment or service.
- Health Care Operations. We may use and disclose your PHI for health care operations (e.g., case management and care coordination, customer service, fundraising, risk management, legal services, compliance, security).
Other Permitted Uses and Disclosures
- Others Involved in Your Care. We may disclose your PHI to your relatives, friends, or to any other person involved in your care, as long as the information is directly relevant to that person’s involvement with your health care or payment for that care.
- Business Associates. We may disclose your PHI to persons with whom we have contracted to help us administer your benefits (our “business associates”). Our business associates are required to appropriately safeguard our patients’ PHI.
- Without Your Written Authorization as Required or Permitted by Law. We may use and disclose your PHI without your written authorization as required or permitted by law. For example:
- Workers’ Compensation. We may disclose your PHI for workers’ compensation or similar programs established by law to provide benefits for work-related injuries or illnesses.
- Law Enforcement. We may disclose your PHI to law enforcement officials for law enforcement purposes.
- Judicial or Administrative Proceedings. We may disclose your PHI in response to a judicial order, subpoena, discovery request, or other lawful process.
- Public Interest. We may disclose your PHI to address matters of public interest (e.g., reporting child abuse and neglect, threats to public health and safety, national security reasons).
- Coroners, Medical Examiners and Funeral Directors. We may disclose your PHI to a coroner, medical examiner or funeral director, as necessary for them to fulfill their duties.
- U.S. Department of Health and Human Services. We may disclose your PHI when required by the Secretary of the U.S. Department of Health and Human Services as part of an investigation or a determination of our compliance with relevant laws.
- Oversight. We may disclose your PHI to a health oversight agency for activities authorized by law (e.g, audits, investigations, inspections, and licensure).
- Health or Safety. We may use and disclose your PHI when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone who might be able to help prevent the threat. For example, we may disclose your PHI in a proceeding regarding the licensure of a dentist.
- Military and Veterans. If you are a member of the armed forces, we may release your PHI as required by military command authorities. We may also release PHI about foreign military personnel to the appropriate foreign military authority.
- Organ, Eye and Tissue Donation. If you are an organ, eye or tissue donor, we may disclose your PHI to an organ donation and procurement organization.
- With Your Written Authorization. The use or disclosure of your PHI for purposes or activities not listed above or otherwise permitted by law will require your written authorization. Your written authorization is required for most uses and disclosures of psychotherapy notes, uses and disclosures of PHI for marketing purposes, and disclosures that are a sale of PHI. If you authorize us to use and disclose your PHI, you may revoke that authorization in writing at any time. If you do so, we will no longer use and disclose your PHI for the reasons covered by your written authorization. However, we are unable to take back any disclosures we have already made with your authorization. If your PHI is disclosed to a third party with your permission, that PHI is no longer subject to this Notice, and the recipient may re-disclose your PHI if the recipient is not subject to federal privacy laws.
Your Rights Regarding Your PHI
You have the rights described below regarding your PHI. In order to assert any such right, you must make your request in writing to Life Dental Group at 2653 West Oxford Loop, Suite 108, or by email at email@example.com .
- Right to Request Restrictions. You have the right to request a restriction or limitation on our use or disclosure of your PHI for treatment, payment or health care operations. You also have the right to request a restriction or limitation on our disclosure of your PHI to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not use and disclose information about a surgery that you have had. In your request, you must tell us: (1) what information you want to limit; (2) whether you want to limit our use, disclosure, or both, of the PHI; and (3) to whom you want the limitations to apply (for example, disclosures to your spouse). We will attempt to accommodate all reasonable restriction requests, but we are not obligated to agree to a request (except as noted in this paragraph), and in certain circumstances we may not be able to comply. We are required to comply with your request that we not disclose certain PHI to a health plan, insurer or other third-party payor for payment or health care operations purposes if the PHI relates solely to treatment or services that have been fully paid out-of-pocket.
- Right to Request Confidential Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you by phone at work, or that we only contact you by mail at home. We will not ask you the reason for your request, and we will attempt to accommodate all reasonable requests.
- Right to Inspect and Copy. You have the right to inspect and copy your PHI that may be used to make decisions about your care. If you request a copy of this PHI, we may charge you for certain reasonable costs associated with your request (copying and mailing or other delivery method). In certain very limited circumstances, we may deny your request to inspect and copy this PHI. In most cases, when you are denied access to this PHI, you may request that the denial be reviewed, and we will comply with the outcome of the review.
- Right to Request Amendment. If you feel that the information in your health and billing records is incorrect or incomplete, you may ask us to amend the information, and you have the right to request an amendment for as long as we keep that information. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: (1) was not created by us, unless the person or entity that created the information is no longer available to make the amendment; (2) is not part of the health, billing or other designated record sets kept by us or for us; (3) is not part of the information that you would be permitted to inspect and copy; or (4) is accurate and complete.
- Right to an Accounting of Disclosures. You have the right to receive an accounting (i.e., a list) of certain disclosures made by us regarding your PHI, including disclosures made to or by our business associates. Generally, you may receive an accounting of disclosures if the disclosure is required by law, was made in connection with public health activities, or in similar situations as those listed above as “Other Permitted Uses and Disclosures.” Your request should state a time period that may not be longer than six years before your request. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved, and you may choose to withdraw or modify your request at that time and before any costs are incurred. You do not have a right to an accounting of disclosures where such disclosure was made:
- for treatment, payment, or health care operations;
- to you about your own PHI;
- incidental to other permitted disclosures;
- where authorization was provided;
- to family or friends involved in your care (where disclosure is permitted without authorization);
- tor national security or intelligence purposes or to correctional institutions or law enforcement officials in certain circumstances; or
- as part of a limited data set where the information disclosed excludes identifying information.
- Right to Revoke Your Written Authorization. You have the right to revoke your written authorization at any time. If you revoke your authorization, we will no longer use or disclose your PHI for the reasons covered by that authorization.
- Right to a Paper Copy of This Notice. You have the right to a paper copy of this Notice, and you may request such a copy at any time by contacting Life Dental Group at 2653 West Oxford Loop, Suite 108, or by email at firstname.lastname@example.org. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. You may also view this Notice on our website at www.LifeDentalGroup.com.
A breach is an unpermitted use or disclosure of PHI in which there is more than a low probability that such PHI has been compromised. We will notify you in the event of a breach of your PHI. If you agree, we may notify you of a breach via email.
Changes to This Notice
We can change the terms of this Notice at any time. If we do, the new terms will be effective for all of the PHI we already have about you as well as any information we receive in the future. The updated Notice will be posted on our website and will be available at our facilities and locations where treatment, payment, or health care operations activities may occur. In addition, the updated Notice will be given to each new patient and is available to all returning patients upon request. If we do so,
If you believe your privacy rights have been violated, you may file a complaint with us by calling Life Dental Group at 662-550-2294 , or by contacting Life Dental Group at 2653 West Oxford Loop, Suite 108, or by email at email@example.com. You may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint.