Miracle Dental Associates, LLC
Notice of Privacy Practices
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 is required by the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA). We are required by law to maintain the privacy of protected health information. Protected health information (PHI) is health information that identifies a patient and relates to a patient’s mental or physical condition, medical treatment, or payment for medical treatment. We are required by law to provide individuals with notice of our legal duties and privacy practices with respect to PHI and to notify affected individuals following a breach of unsecured PHI.
This Notice describes how Miracle Dental Associates protects the confidentiality of your health care information in our possession and outlines the ways in which we may use and disclose PHI about you. We must follow the privacy practices described in this Notice as long as it is in effect and also comply with any more stringent requirements under federal or state law. This Notice takes effect September 1, 2016, 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, and to make new Notice provisions effective for all PHI that we maintain. When we make a significant change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at our practice location, and we will provide copies of the new Notice 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 using the information listed at the end of this Notice.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
We may use and disclose your health information for different purposes, including treatment, payment, and health care operations. Below are examples for each of these categories. Some information, such as HIV-related information, genetic information, alcohol and/or substance abuse records, and mental health records may be entitled to special confidentiality protections under applicable state or federal law. We will abide by these special protections as necessary.
Permitted Uses and Disclosures. Under HIPAA, Miracle Dental Associates is permitted to use and disclose your personal health information for certain purposes without your prior authorization. These permitted uses and disclosures include:
Treatment – We may use and disclose your health information for your treatment. For example, we may disclose your health information to a specialist providing treatment to you.
Payment – We may use and disclose your health information to obtain reimbursement for the treatment and services you receive from us or another entity involved with your care. Payment activities including billing, collections, claims management, and determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party. For example, we may send claims to your dental health plan containing certain health information.
Health Care Operations – We may use and disclose your health information in connection with our health care operations. For example, health care operations include quality assessment and improvement activities, conducting training programs, and licensing activities.
Miracle Dental Associates uses administrative, technical, and physical safeguards to maintain the privacy of your personal health information, and we are required by law to limit the use and disclosure of your personal health information to the minimum amount necessary.
Uses and Disclosures of Personal Health Information to Other Entities
Miracle Dental Associates may disclose your personal health information to other entities, business associates, or individuals (as permitted by HIPAA) who assist us in delivering health care services to our patients. These parties are required by law to sign a contract with Miracle Dental Associates agreeing to protect the confidentiality of your personal health information.
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Under HIPAA, Miracle Dental Associates is permitted to use and disclose your personal health information without your prior authorization under the following conditions:
Disclosures required by HIPAA
Disclosures to the Secretary of the U.S. Department of Health and Human Services – We are required to disclose your protected health information to the Secretary of the U.S. Department of Health and Human Services when the Secretary is investigating or determining our compliance with the HIPAA Privacy Rule.
Disclosures to You – We are required to disclose to you most of your protected health information that is in a “designated record set” (defined by HIPAA Privacy Rule) when you request access to this information. Generally, a designated record set contains medical and billing records, as well as other records that are used to make decisions about your health care. We are also required to provide, upon your request, an accounting of certain disclosures of your protected health information that are for reasons other than treatment, payment and health care operations.
Uses and Disclosures Requiring You to Have an Opportunity to Agree or Object
Unless you object, Miracle Dental Associates may disclose your health information to a family member, close friend, or other person you have identified as being involved in your care or in the payment for your care. Additionally, we may disclose information about you to a patient representative. If a person has the authority by law to make health care decisions for you, we will treat the patient representative the same way we would treat you with respect to your health information. We also may disclose your information to assist in disaster relief efforts. If you are not present or able to agree to these disclosures of your health information, then we may, using our professional judgment, determine whether the disclosure is in your best interest.
Uses Requiring Your Written Authorization
We are required to obtain your written authorization for use or disclosure of your health information in the following instances:
OTHER USES OF PERSONAL HEALTH INFORMATION – AUTHORIZATION
Other uses and disclosures of personal health information not described above will be made only with your written authorization. If you provide us with such written authorization, you may revoke that authorization in writing at any time, and this revocation will be effective for future uses and disclosures of personal health information. However, the revocation will not be effective for information that we already have used or disclosed in reliance on the authorization.
OTHER USES OF PERSONAL HEALTH INFORMATION – AUTHORIZATION
The following is a description of your rights with respect to your Protected Health Information.
Right to Inspect and Copy. You have the right to inspect and obtain a copy of your PHI. You may access your PHI by submitting your request in writing to the privacy contact listed at the end of this Notice. You must include (1) your name, address, telephone number and date of birth and (2) a description of the PHI you are requesting. Miracle Dental Associates may charge a reasonable fee for providing you copies of your PHI. We only maintain the PHI that we create and obtain in providing your health care services.
Right to Request Restrictions. You have the right to request a restriction on the PHI we use or disclose about you for treatment, payment or health care operations. We will consider your request but are not legally required to accept it. If Miracle Dental Associates accepts your request, we will put any limits in writing and abide by them except in emergency situations. You may not limit the uses and/or disclosures that we are legally required or allowed to make.
Right to Amend. You have the right to correct or update your PHI. This means that you may request an amendment of your PHI for as long as Miracle Dental Associates maintains this information. In certain cases, Miracle Dental Associates may deny your request for amendment. If so, you have the right to file a statement of disagreement with Miracle Dental Associates. We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. If your PHI was sent to us by another entity, we may refer you to that entity to amend your PHI. (i.e., if applicable, to the patient’s pediatrician). Please contact Miracle Dental Associates as noted below if you have questions about amending your PHI.
Right to Request Confidential Communications. You have the right to request or receive confidential communications from Miracle Dental Associates by alternative means or at a different address. We will agree to accommodate a reasonable request if disclosure of your PHI through standard means of communication could endanger you. You may be required to provide us with a written statement of possible danger, a different address, or another method of contact or information as to how payment will be handled.
Right to an Accounting of Disclosures. You have the right to receive an accounting of certain disclosures Miracle Dental Associates has made of your PHI. This right does not apply to disclosures for purposes of treatment, payment, or health care operations. Your request may be for disclosures made up to six (6) years before the date of your request, but in no event for disclosures made before April 14, 2003. Please contact Miracle Dental Associates if you would like to receive an accounting of disclosures or if you have questions about this right.
Right to a Paper Copy of this Notice. You have the right to receive a paper copy of this Notice. Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy. To obtain a paper copy of this Notice, please contact Miracle Dental Associates per the information at the end of this Notice.
If you believe that any of your privacy rights have been violated, you may file a written complaint with Miracle Dental Associates using the contact information at the end of this Notice. You may contact Miracle Dental Associates to obtain the complaint form. You may complain to Miracle Dental Associates by submitting the complaint form to us in writing, at the address provided at the end of this Notice. If you believe any of your privacy rights have been violated, you may also submit a written complaint to the Secretary of 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. You may also file a written complaint to Miracle Dental Associates using the procedure listed in this section in response to a denial by us regarding any of your individual rights listed in this Notice. For example, if you disagree with a decision we made about access to your PHI or in response to a request you made to amend or restrict the use or disclosure of your PHI.
We support your right to protect the privacy of your protected health information. You will not be retaliated against in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
For questions about this Notice of Privacy Practices, or if you wish to file a complaint, please contact:
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The first step towards a beautiful, healthy smile is to schedule an appointment.
Please contact our office by phone or complete the appointment request form below. Our scheduling coordinator will contact you to confirm your appointment. If you are an existing patient, this contact form should not be utilized for communicating private health information.