Our >See pages 3 and 4 ,Uses and ,Disclosures,Your ,Choices,Your ,Rights,Your Information.
,Your Rights.,Our Responsibilities.,You have the right to:,Get a copy of your paper or electronic medical record,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,You have some choices in the way that ,we use and share information as we:,Tell family and friends about your condition,Provide disaster relief,Include you in a hospital directory,Provide mental health care,Market our services and sell your information,Raise funds,We may use and share your information as we:,Treat you,Run our organization,Bill for your services,Help with public health and safety issues,Do researchfor more information ,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,Respond to lawsuits and legal actions,This notice describes how healthl information about you ,may be used and disclosed and how you can get access ,to this information.
Please review it carefully.,>See page 2 for ,more information on ,these rights and how ,to exercise them,>See page 3 for ,more information on ,these choices and ,how to exercise them,on these uses and ,disclosures,Notice of Privacy Practices • Page 1,Your ,RightsThis section explains your rights and someof our responsibilities to help you.,When it comes to your health information, you have certain rights.,Get a copy of thisYou can ask for a paper copy of this notice at any time, even if you have agreed to,privacy notice,receivethe notice electronically.
We will provide you with a paper copy promptly.,Get an electronic or•You can ask to see or get an electronic or paper copy of your medical record and,paper copy of yourother health information we have about you.
Ask us how to do this.,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•You can ask us to correct health information about you that you think is incorrect,yourmedical recordor incomplete.
Ask us how to do this.,We may say “no” to your request, but we’ll tell you why in writing within 60 days.,Request confidential•You can ask us to contact you in a specific way (for example, home or office phone),communicationsor to send mail to a different address.,We will say “yes” to all reasonable requests.,Ask us to limit what ,we use or share,You can ask us not to use or share certain health information for treatment, ,payment, or our operations.
We are not required to agree to your request, and we ,may say “no” if it would affect your care.,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,You can ask for a list (accounting) of the times we’ve shared your health information ,for six years prior to the date you ask, who we shared it with, and why.,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.,Choose someone ,to act for you,If you have given someone medical power of attorney or if someone is your legal ,guardian, that person can exercise your rights and make choices aboutyour health ,information.,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 complain if you feel we have violated your rights by contacting us using the ,information on page 1.,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.,Notice of Privacy Practices • Page 2,Your ,Choices,For certain health information, you can tell Kids Dental Care 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 the case of fundraising:,We may contact you for fundraising efforts, but you can tell us not to,Our ,Uses and ,Disclosures,We typically use or share your health information in the following ways.,How does Kids Dental Caretypically use or share your health information?,contact you again.,We can use and share your health ,information to run our practice, improve ,your care, and contact you when necessary.and services.,We can use and share your health ,information to bill and get payment from ,health plans or other entities.,Example:A doctor treating you for ,an injury asks another doctor about ,your overall health condition.,Example:We use health information ,about you to manage your treatment ,Example:We give information about you ,to your health insurance plan so it will pay ,for your services.,Treat you•We can use your health information and,share it with other professionals who are ,treating you.,Run our ,organization,Bill for your ,services,In these cases, you have ,both the right and choice ,to tell us to:,Share information with your family, close friends, or others involved in your care,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:,Marketing purposes,Sale of your information,Most sharing of psychotherapy notes,Continuedon next page,Notice of Privacy Practices • Page 3,Respond to lawsuits andWe can share health information about you in response to a court or,legal actions,administrative order, or in response to a subpoena.,Notice of Privacy Practices • Page 4,organizations.,tissue donation requests,Work with a medical,We can share health information with a coroner, medical examiner, or funeral,examiner or funeral director,director when an individual dies.,Respond to organ andWe can share health information about you with organ procurement,How else Kids Dental Care uses or shares 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,We can share health information about you for certain situations such as:,Preventing disease,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•We can use or share your information for health research.,Comply with the law•Wewill share information about you if state or federal laws require it,,including with the Department of Health and Human Services if it wants to ,see that we’re complying with federal privacy law.,Address workers’ ,compensation, law ,enforcement, and other ,government requests,We can use or share health information about you:,For workers’ compensation claims,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,Kids Dental Care Responsibilities,We are required by law to maintain the privacy and security of your protected health information.,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: www.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.,Notice of Privacy Practices • Page 5,This Notice of Privacy Practices applies to the following organizations.,Kids Dental Care,733 Terryville Avenue,Bristol, CT 06010,Kids Dental Care Windsor,697 Poquonock Avenue,Windsor, CT 06789,Coming Soon:,Kids Dental Care New Britain