NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
REVIEW IT CAREFULLY.
Health Insurance Portability & Accountability Act of 1996 (HIPAA) requires
all health care records and other individually identifiable health information
used or disclosed by us in any form, whether electronically, on paper, or
orally, are kept confidential. This federal law gives you, the patient,
significant new rights to understand and control how your health information
is used. HIPAA provides penalties for covered entities that misuse personal
health information. As required by HIPAA, we have prepared this explanation
of how we are required to maintain the privacy of your health information
and how we may use and disclose your health information.
Without specific written authorization, we are permitted to use and disclose
your health care records for the purposes of treatment, payment and health
- Treatment means providing, coordinating, or managing health care and related services
by one or more health care providers. For example, we may need to share
information with other providers or specialists involved in the continuation
of your care.
- Payment means such activities as obtaining reimbursement for services, confirming
coverage, billing or collection activities, and utilization review.
For example, we disclose treatment information when billing a dental
plan for your dental services.
care operationsinclude the business aspects of running our practice. For example, patient
information may be used for training purposes, or quality assessment.
you request otherwise, we may use or disclose health information to a family
member, friend, or other personal representative to the extent necessary
to help with your healthcare or with payment for your healthcare. In addition,
we may use your confidential information to remind you of appointments by
sending reminder postcards and/or leaving messages at home and/or work.
Any other uses and disclosures will be made only with your written authorization.
You may revoke such authorization in writing and we are required to honor
and abide by that written request, except to the extent that we have already
taken actions relying on your authorization.
have certain rights in regards to your protected health information, which
you can exercise by presenting a written request to ourPrivacy Officer at
the practice address listed below:
- The right
to request restrictions on certain uses and disclosures of protected
health information, including those related to disclosures to family
members, other relatives, close personal friends, or any other person
identified by you. We are, however, not required to agree to a requested
restriction. If we do agree to a restriction, we must abide by it unless
you agree in writing to remove it.
right to request to receive confidential communications of protected
health information from us by alternative means or at alternative locations.
right to access, inspect and copy your protected health information.
right to request an amendment to your protected health information.
right to receive an accounting of disclosures of protected health information
outside of treatment, payment and health care operations.
right to obtain a paper copy of this notice from us upon request.
We are required by law to maintain the privacy of your protected health
information and to provide you with notice of our legal duties and privacy
practices with respect to protected health information.
This notice is effective as of April 15, 2003 and we are required to abide
by the terms of the Notice of Privacy Practices currently in effect. We
reserve the right to change the terms of our Notice of Privacy Practices
and to make the new notice provisions effective for all protected health
information that we maintain. Revisions to our Notice of Privacy Practices
will be posted on the effective date and you may request a written copy
of the Revised Notice from this office.
You have recourse if you feel that your privacy protections have been violated.
You have the right to file a formal, written complaint with us at the address
below, or with the Department of Health & Human Services, Office of
Civil rights,in the event you feel your privacy rights have been violated.
We will not retaliate against you for filing a complaint.
contact us for more information:
more information about HIPPA or to file a complaint:
City, State, Zip
Craig C. Pettey DDS, INC.
10551 Mills Road
Houston, Texas 77070
U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
(877) 696-6775 (toll-free)