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. This notice describes the privacy practices of Pine Creek Dental.
How to Contact Us
If you have any questions or would like further information about this notice, you can either
Dr. Bill Thompson
9475 Briar Village Point Suite #115
Colorado Springs, CO 80920
or call: 719-268-9400
Information Covered By This Notice
We create and maintain records about the dental care and services you receive at Pine Creek Dental. Having these records helps us to provide you with quality care and to comply with certain legal requirements. This notice applies to health information about you that we create or receive and that identifies you. This notice tells you about the ways we may use and disclose health information about you. It also describes your rights and certain obligations we have with respect to your health information.
We are required by law to:
- maintain the privacy of health information that identifies you;
- give you this notice of our legal duties and privacy practices with respect to that information; and
- abide by the terms of our privacy notice that is currently in effect.
Copies of our Privacy Notice will be posted in our office and are, at all times, available upon request.
How We May Use and Disclose Health Information About You
We describe below the reasons we may use and disclose health information about you. For each category, we will explain what we mean and give you examples.
We may use health information about you to provide you with dental treatment or services. We may disclose health information about you to dental specialists, physicians, or other health care professionals involved in your care. For example, a periodontist treating you for periodontal disease may need to know if you have a heart condition because it could necessitate antibiotics before treatment.
We may use and disclose your health information so the treatment and services you receive may be billed to, and payment may be collected from, an insurance carrier or other entity. For example, we may need to give your health insurance provider information about care you received at our office so they will pay us or reimburse you for the services.
Health Care Operations
We may use and disclose health information about you in connection with a wide range of health care operations. These uses and disclosures are necessary to run our practice and to help ensure that our patients receive appropriate care. For example, we may use health information about you to review our treatment and services and evaluate the performance of our staff of health care professionals.
We may use or disclose health information about you when contacting you to remind you of a dental appointment. We may contact you by using a postcard, letter, voicemail, text or E- mail.
We may use and disclose health information about you to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-related Benefits and Services
We may use and disclose health information about you to tell you about health-related benefits and services that may be of interest to you. Disclosure to Individuals Involved in Your Care or Payment for Your Care. We may disclose health information about you to a family member or friend who is involved with your care or payment for your care. If you do not object, or if you are not present and we believe it is in your best interest to do so, we may tell your family or others responsible for your care of your location, condition, or death. In addition, we may disclose health information about you to an entity assisting in a disaster relief effort so your family or others responsible for your care can be notified about your location, condition, or death.
Disclosures Required by Law
We may use or disclose health information about you to the extent we are required by law to do so.
Public Health Activities
We may disclose health information about you for certain public health activities and purposes. These activities and purposes generally include the following:
- preventing or controlling disease, injury or disability;
- reporting product defects;
- notifying people of recalls of products they may be using; and
- notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
Victims of Abuse, Neglect or Domestic Violence
Under certain circumstances, we may disclose to the appropriate government authority health information about an individual whom we believe is a victim of abuse, neglect or domestic violence. We will make this disclosure only (i) if you agree or (ii) to the extent required or authorized by law and we believe the disclosure is necessary to prevent serious harm.
Health Oversight Activities
We may disclose health information about you to a health oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, licensure actions and other activities necessary for the government to provide appropriate oversight of the health care system, certain government benefit programs, and compliance with certain civil rights laws.
Lawsuits and Legal Actions
If you are involved in a lawsuit or other legal action, we may disclose health information about you in response to a court or administrative order. We also may disclose health information about you in response to a subpoena, discovery request, or other lawful process that is not ordered by a court, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Law Enforcement Purposes
We may disclose health information about you for a law enforcement purpose to a law enforcement official:
- as required by law or in response to a court order, warrant, subpoena, summons or similar process;
- to identify or locate a suspect, fugitive, material witness or missing person;
- if you are an actual or suspected victim of a crime and you agree to the disclosure or, under certain limited circumstances, if we are unable to obtain your agreement;
- to alert law enforcement of your death if we suspect it may have resulted from criminal conduct;
- if we believe the information shows evidence of criminal conduct at our office; or
- if we are providing care in response to a medical emergency, if necessary to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.
Coroners, Medical Examiners and Funeral Directors
We may disclose health information to a coroner or medical examiner to identify a deceased person, determine the cause of death or undertake other authorized duties. We also may release health information to funeral directors as necessary to carry out their duties.
Serious Threat to Health or Safety
We may use or disclose health information about you if we believe it is necessary to do so to prevent or lessen a serious threat to anyone’s health or safety. We would make such a disclosure only to someone able to help prevent or lessen the threat or, under certain circumstances, if the disclosure is necessary for law enforcement authorities to identify and apprehend an individual.
Specialized Government Functions
If you are a member of the armed forces, we may, under certain circumstances, use and disclose health information about you as required by military command authorities. We also may use and disclose health information about foreign military personnel to the appropriate foreign military authority. We may disclose health information about you to authorized federal officials to (i) conduct certain national security activities, (ii) provide protection to the President or other authorized people, or (iii) conduct certain investigations. We may disclose to a correctional institution or law enforcement official having custody of an individual health information about that individual.
We may disclose health information about you to comply with laws relating to workers’ compensation or similar programs that provide benefits for work-related injuries or illness.
Other Uses of Health Information
We will make other uses and disclosures of health information not discussed in this notice only with your written authorization. If you authorize us to use or disclose health information about you, you may revoke that authorization at any time. Your revocation must be in writing. If you revoke your prior authorization, we will no longer use or disclose health information about you for the reasons covered by that authorization. You cannot revoke your authorization to the extent that we have already taken action based on that authorization. For example, we are unable to take back any disclosures we have already made with your authorization.
Right of Access
You may inspect and request a copy of certain health information we have about you. We have forms for such requests. These requests must be made in writing and must be directed to our contact officer listed on the first page of this notice. We will provide a copy in a format you request if it is readily producible. If not readily producible, we will provide it in a hard copy format or other format that is mutually agreeable. If you are the recipient of electronic notice, you may obtain a paper copy upon request.
We will charge a reasonable, cost-based fee when asked to provide copies of your health information. Charges will include costs for copying at $33 per family. If you request a summary of your health information, we will provide it, charging staff time at the hourly rate shown above. If you have any questions about our fees for these services, please contact us using the contact information provided above.
Right to Amend
If you believe that health information we have about you is incorrect or incomplete, you may ask us to amend the information. Such requests must be made in writing and must include a reason to support the request. Under some circumstances, we may deny such a request, but you are entitled to a written response within 60 days of our receipt of your written request.
Right to Request Restrictions
You may request that we restrict uses or disclosures of certain health information about you to carry out treatment, payment, or health care operations. We may not (and are not required to) agree to requested restrictions. We will not use or disclose any health information about you in violation of any restrictions that we agree to other than in providing emergency treatment.
Confidential Communications: Alternative Means, Alternative Locations
You may ask to receive communications of health information by alternative means or at an alternative location. We will accommodate all reasonable requests. You must provide this type of request to us in writing and provide an alternative method of contact or alternative address. We will provide an estimate of the fee for this service in advance and ask that you provide information as to how payment will be handled.
Accounting of Disclosures
You have a right to receive an accounting of disclosures we have made of health information about you for the six years prior to the date that the accounting is requested except for disclosures to carry out treatment, payment, health care operations, and certain other disclosures. The first such accounting we provide within any 12 month period will be without charge to you. We will charge a reasonable, cost-based fee for each subsequent request for an accounting within a 12 month period. We will notify you in advance of this fee.
Right to a Paper Copy of this Notice
You have the right to a paper copy of this notice. You may ask us to give you a copy of the notice at any time. Even if you have agreed to receive the notice electronically, you may still obtain a paper copy. To obtain a paper copy, ask any Pine Creek Dental staff member.
Changes to This Notice
We reserve the right to change the terms of this notice and to make the changed notice provisions effective for all health information we have about you or create or receive in the future. We will promptly revise, post, and distribute a revised notice whenever there is a material change to the uses or disclosures, individual’s rights, our legal duties, or other privacy practices discussed in this notice. Our privacy notice will contain on the first page, in the top right-hand corner, the effective date.
If you have any complaints about your privacy rights or how your health information has been used or disclosed, you may file a complaint by contacting the U.S. Department of Health and Human Services.
The U.S. Department of Health and Human Services
200 Independence Avenue, S.W., Washington, D.C. 20201
Toll Free: 1-877-696-6775
The privacy of your health information is important to us. We will not retaliate against you in any way if you choose to file a complaint.