This notice describes the ways the Center for Dental Excellence uses and discloses your medical information and how you can get access to this information. Please read it carefully.
It should be noted that Provider is not obligated to provide an environment that can prevent patients or third parties from incidentally overhearing your Protected Health Information.
A Summary of The Circumstances Under Which and Purposes for Which Your Oral Health Information May Be Used and Disclosed:
To Aid in Proper Treatment: Provider is authorized to use your health information in order to provide adequate care to you and disclose your health information to those who may provide care to you. For instance, doctors involved in your care will require the necessary information regarding your symptoms before prescribing appropriate medications. Provider also may disclose your health care information to personnel outside of the Provider who may be involved in your care including members of your family, suppliers of dental equipment or medical supplies, pharmacists and other healthcare professionals.
To Collect Payment: Provider may list your health information in payment invoices in order to collect fees from third parties for the care you receive from Provider. For instance, Provider may be required by your health insurance company to provide information pertaining to your health care status for the purposes of reimbursement by the state to you or Provider. Provider may also need to receive prior approval from your health insurer and may need to explain to the health insurer your needs for obtaining health care and the services that will be provided to you.
To Perform Health Care Procedures: Provider is authorized to use and disclose your health information in order to properly perform various health procedures. Health care procedures can include activities such as:
- Provide a quality assessment and activities for improvement.
- Activities that are designed to improve your health or reduce healthcare costs.
- Protocol development, care coordination, and case management.
- Contacting various healthcare providers and patients with information regarding treatment alternatives and other functions that do not include treatment.
- For uses of professional reviews and performance evaluations.
- To aid in training programs, including those in which students, practitioners in healthcare and trainees can learn under proper supervision.
- Training non-healthcare professionals.
- Certification, accreditation, licensing, and credentialing activities.
- Contacting health care providers and patients with information about treatment alternatives and other functions that do not include treatment.
- Reviewing and auditing, including compliance reviews, medical and dental reviews, compliance programs, and legal services.
- Business development and planning including cost management and planning related analyses, as well as formulary development.
- Business management and general administrative activities of Provider.
- Marketing activities of Provider.
- Provider may use your health information for the purposes of staff performance evaluation, and may combine your health information with other Provider patients in order to evaluate how to more effectively serve all of Provider’s patients, and may also disclose your health information to Provider’s staff and contracted personnel for training purposes, and may use your health information to contact you as an appointment reminder.
To Remind You of Appointments: Provider may use and disclose your health information when contacting you as part of an appointment reminder for treatment or dental care with Provider. The Center for Dental Excellence, S.C. may contact you with appointment reminders in the form of voicemail messages, text messages, email messages or postcards. Provider will send you a notice 1-3 weeks in advance to remind you of an upcoming appointment or to let you know that you are due for an appointment. If you do not wish for us to contact you in this manner or for this reason, please contact our Privacy official, Jennifer Tracy at (920) 662-1440.
For Recommending Treatment Alternatives: Provider is authorized to use and disclose your health information to inform you of or recommend certain treatment options or alternative therapies that may interest you.
To Provide to Individuals Involved With Your Care or Payment For Your Care Where You Don’t Object: Provider may share your medical information to a caregiver who may be a family member, friend, or other individuals. The provider may also share information with anyone who helps to pay for your care. If you are not able to object to this communication, the Provider may discuss your medical information or payment status with a friend, family member, or other person based on our professional judgment. If Provider believes you may object based on professional judgement, the Provider will not share or discuss your health information with a family member, friend, or other person. The provider will only discuss or share information that is related to your care.
Under Legal Obligation: Provider is authorized to disclose your health information when it is required to do so by any Federal, State or local law. Where Wisconsin law is more restrictive than Federal privacy regulations, the Provider will comply with State law including regulations diagnosis or health status as it relates to mental health, drug use, alcoholism, or HIV.
Preventing Risks to Public Health: Provider is authorized to disclose your health information for the following purposes and public activities:
- The prevention or controlling of disease, disability or injury, or to report a disease, injury, vital events like births or deaths, and the conduct of public health surveillance, as well as investigations and interventions.
- To report adverse events, track products, report product defects, or enable product recalls, repairs and replacements, as well as to remain compliant with requirements as established by the Food and Drug Administration.
- No notify anyone who has been exposed to a communicable disease or who may be at risk of spreading or contracting a disease.
- To provide to an employer information about an individual who is a member of a workforce and who is legally required.
- To report neglect, abuse, or domestic violence. The provider is authorized to notify government authorities if the Provider believes a patient is a victim of neglect, abuse, or domestic violence. Provider will only disclose this information when specifically required or authorized by law or when the patient agrees to the disclosure of said information.
To Engage In Health Oversight Activities: Provider is authorized to disclose your health information to a health oversight agency for certain activities that may include: civil, administrative or criminal investigations; audits; inspections; disciplinary action or licensure. The provider is not authorized to disclose your health information if happen to be the subject of an investigation and the investigation does not originate from and is unrelated to your receipt for health care or public benefits.
In Conjunction With Administrative and Judicial Proceedings: State law may permit or require that Provider disclose your health information as part of a judicial or administrative proceeding that may be in response to a court order or administrative tribunal as expressly authorized by the court order or in response to a subpoena, unlawful process or discovery request. However, this will only take place when the provider makes reasonable efforts to notify you of the request or to obtain an order that protects your healthcare information.
When Requested by Law Enforcement: State law may permit or require Provider to disclose your health information to an official of law enforcement for certain law enforcement purposes that may include, under some limited circumstances, if you happen to be the victim of a crime or a crime needs to be reported.
When Requested by Medical Examiners and Coroners: Provider is authorized to disclose your health information to medical examiners and coroners in order to determine the cause of death or for other duties authorized by law.
When Requested by Funeral Directors: Provider is authorized to disclose your health information to funeral directors as directed by local and state laws for the purposes of carrying out their duties with regard to your funeral arrangements. If their duties call for it, the Provider is authorized to disclose your health information prior to and in reasonable anticipation of your death.
For the Purposes of Eye, Tissue Or Organ Donation: Provider is authorized to disclose or use your health information to various organ procurement organizations or other entities that may engage in the procurement, banking or transplantation of eyes, tissues, or organs for the purposes of donation or transplantation.
For Medical Research: Provider is under some rare circumstances authorized to use your health information for medical research purposes. Prior to Provider disclosing any of your health information for research purposes, the project will need to pass an extensive approval process.
When Facing a Serious Threat to Safety or Health: Federal, State, and Local laws may require or permit Provider to act in good faith when disclosing your health information in order to prevent or lessen a dire and immediate threat to your health or safety, or the health and safety of the general public.
For Certain Functions of Government: Some circumstances, under Federal regulations, require or permit Provider to disclose your health information in order to satisfy a government function that may be related to the military or veterans, intelligence activities, or national security. Other circumstances include the protective services for the President and others, inmates and law enforcement custody, and medical suitability determinations.
For The Purposes of Worker’s Compensation: Provider is authorized to release your health information for the purposes of worker’s compensation or other similar programs.
When Provider is Authorized to Use or Disclose Health Information
In addition to the matters stated above, Provider is not permitted to disclose your health information without your written permission. If you or a representative of your choosing authorizes Provider to disclose or use your health information, you may revoke that permission in writing at any time.
Your Health Information Rights
You have the following rights with regards to the health information Provider maintains on your behalf:
Request Restrictions: You have the right to restrict the usage and disclosure of your health information at all times. You may request a limit on Provider’s disclosure of your health care information to anyone involved in your care or the payment of said care. On the other hand, PRovider is not required to agree to any requests.
Confidential Communications: You have the right to request that Provider communicates with you in a particular way. For instance, you might request that Provider only contact you regarding your health information in person and with no other family members present.
Provider will not request that you provide any reasons for your request and will attempt to honor your requests for confidential communications.
The provider is not authorized to request that you provide any reasons for your request and will do all that is possible to honor reasonable requests for confidential communications. The provider is not authorized or required to agree to your request. Where Provider agrees to one or more requests, the request will be followed unless the information is required to provide you with emergency dental or medical treatment.
Right to Receive, Inspect, or Copy Your Health Information: You have the right to copy and inspect your health information, including all billing records. A request to inspect or copy your health information may require a reasonable fee to be paid to Provider for the purposes of copying and assembling your health information. You may also request to have your health information delivered via digital format. You will typically receive the requested health information within 30 days or less.
Amending Your Health Information: You or a representative of your choosing have the right to request that Provider amend your health records, if you believe that the information is inconsistent or incorrect. That request may be made as long as the information is indeed maintained by Provider. A request for amendment of your health records must be made in writing. Provider has the right to deny You or your representative have the right to request that Provider amend your records, if you believe your health information records are incorrect or incomplete. That request may be made as long as the information is maintained by Provider. A request for an amendment of records must be made in writing. Provider may deny your request if it is not made in writing or if it does not include a reason for the amendment. The request may also be denied if your health records were not originally created by Provider, or if the records you are requesting are not part of the records kept by Provider. Also, your request may be denied if the health information you wish to amend is not part of the health information that you or a representative of your choosing have the right to inspect or copy, or if, in the Provider’s opinion, the records containing your health information are complete and accurate.
Accounting Rights: You have the right to request an accounting of the disclosure of your health information made by Provider for purposes other than treatment, payment for services, or operations, including purposes that may be authorized by law and research programs. The request for an accounting of disclosure of your health information must be made in writing. Accounting requests may not be made for periods of time that are in excess of six (6) years before the date of the request date. Provider will provide the first accounting of your request during any 12-month period without adding a charge. Any requests that follow may be subject to a reasonable fee.
Breach Notifications: You have the right to receive prompt notifications if a breach occurs that may have compromised the security or privacy of your information.
Restricting Disclosures of Self Pay Items to Health Care Plans: You have the right to restrict the disclosure of your health care information to health or insurance companies for the purposes of payment for your services. You must identify the treatments or services provided and the dates that those services were rendered when you are making the request to apply this restriction. You or a representative of your choosing must pay out-of-pocket for your services in full. Where you do not pay for services in full, Provider has the right to revoke this particular restriction. This right cannot be applied where services have already been transmitted to the health or insurance plan providers.
Contact Us with Questions
The provider has appointed Office Manager, Jennifer Tracy, as the contact person for all issues regarding the privacy of your health information and your rights under the Federal privacy standards. You may contact Jennifer at 410 Security Blvd. Green Bay, WI 54313 or call (920) 662-1440 for all requests, rights, complaints, and questions about this notice.
Signed by The Center for Dental Excellence on 3.28.17.