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Notice Of
Privacy Practices
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THIS NOTICE
DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
THE PRIVACY OF YOUR
HEALTH INFORMATION IS IMPORTANT TO US.
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For purposes of this Notice
"us" "we" and "our" refers to Ottley Smiles Dental Center and "you" or
"your" refers to our patients (or their legal representatives as
determined by us in accordance with Florida informed consent law). When
you receive health-care services from us, we will obtain access to your
medical information (e.g., your health history). We are committed to
maintaining the privacy of your health information and we have
implemented numerous procedures to ensure that we do so.
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Florida law and the Health
Insurance Portability & Accountability Act of 1996 (HIPAA) require us to
maintain the confidentiality of all your health-care records and other
individually identifiable health information used by or disclosed to us
in any form, whether electronically, on paper, or orally "PHI" or
Protected Health Information). HIPAA is a federal law that gives you
significant new rights to understand and control how your health
information is used. HIPAA and Florida law provide penalties for covered
entities and records owners, respectively, that misuse or improperly
disclose PHI.
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Starting April 14, 2003,
HIPAA requires us to provide you with this Notice of our legal duties
and the privacy practices we are required to follow when you first come
into our office for health-care services. If you have any questions
about this Notice, please ask to speak to our privacy officer, Dr.
Karina Ottley.
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| Our doctors, clinical
staff, Business Associates (outside contractors we hire), employees and
other office personnel follow the policies and procedures set forth in
this notice. If your regular doctor is unavailable to assist you (e.g.
illness, on-call coverage, vacation, etc.), we may provide you with the
name of another health-care provider outside our practice for you to
consult with by telephone. If we do so, that provider will follow the
policies and procedures set forth in this notice or those established
for his or her practice, so long as they substantially conform to those
for our practice. |
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OUR RULES ON HOW WE MAY USE
AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION
Under the law 456.074, Fla. Stats., and HIPAA), we must have your
signature on a written, dated Consent form and/ or an Authorization form
(not an Acknowledgment form) before we will use and disclose your PHI for
certain purposes as detailed in the rules below.
Documentation You will be asked to sign a Consent form and/or an
Authorization form when you receive this Notice of Privacy Practices. If you
did not sign such a form or need a copy of the one you signed, please
contact our privacy officer. You may take back or revoke your Consent or
Authorization at any time (unless we already have acted based on it) by
submitting our Revocation form in writing to us at our address listed below.
Your revocation will take effect when we actually receive it. We cannot give
it retroactive effect, so it will not affect any use or disclosure that
occurred in our reliance on your Consent or Authorization prior to
revocation (e.g., if after we provide services to you, you revoke your
Authorization or Consent in order to prevent us billing or collecting for
those services, your revocation will have no effect because we relied on
your Authorization or Consent to provide services before you revoked it).
General Rule If you do not sign our Consent form or if you revoke it,
as a general rule (subject to exceptions described below under �Healthcare
Treatment, Payment and Operations Rule� and �Special Rules�), we cannot in
any manner use or disclose to anyone (excluding you, but including payers
and Business Associates) your PHI or any other information in your medical
record. Under Florida law, we are unable to submit claims to payers under
assignment of benefits without your signature on our Consent form. We will
not condition treatment on your signing an Authorization, but we may be
forced to decline you as a new patient or discontinue you as an active
patient if you choose not to sign the Consent or revoke it.
Health-care Treatment,
Payment and Operations Rule With your signed Consent, we may use or
disclose your PHI in order:
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* To provide you with or
coordinate health-care treatment and services. For example, we may
review your health history form to form a diagnosis and treatment plan,
consult with other doctors about your care, delegate tasks to ancillary
staff, call in prescriptions to your pharmacy, disclose needed
information to your family or others so they may assist you with home
care, arrange appointments with other health-care providers, schedule
lab work for you, etc.; |
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* To bill or collect
payment from you, an insurance company, a managed-care organization, a
health benefits plan or another third party. For example, we may need to
verify your insurance coverage, submit your PHI on claim forms in order
to get reimbursed for our services, obtain pre-treatment estimates or
prior authorizations form your health plan or provide your X-rays
because your health plan requires them for payment; or |
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* To run our office,
assess the quality of care our patients receive and provide you with
customer service. For example, to improve efficiency and reduce costs
associated with missed appointments, we may contact you by telephone,
mail or otherwise remind you of scheduled appointments, we may leave
messages with whomever answers your telephone or e-mail to contact us
(but we will not give out detailed PHI), we may call you by name from
the waiting room, we may ask you to put your name on a sign-in sheet, we
may tell you about or recommend health-related products and
complementary or alternative treatments that may interest you, we may
review your PHI to evaluate our staff's performance, or our privacy
officer may review your records to assist you with complaints. If you
prefer that we not contact you with appointment reminders or information
about treatment alternatives or health-related products and services,
please notify us in writing at our address listed above and we will not
use or disclose your PHI for these purposes.
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Special Rules
Notwithstanding anything else contained in this Notice, only in
accordance with applicable law, and under strictly limited
circumstances, we may use or disclose your PHI without your permission,
Consent or Authorization for the following purposes:
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* When required under
federal, state or local law; |
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* When necessary in
emergencies to prevent a serious threat to your health and safety or the
health and safety of other persons; |
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* When necessary for
public health reasons (e.g., prevention or control of disease, injury or
disability; reporting information such as adverse reactions to
anesthesia; ineffective or dangerous medications or products; suspected
abuse, neglect or exploitation of children, disabled adults or the
elderly; or domestic violence); |
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* For federal or state
government health-care oversight activities (e.g., civil rights laws,
fraud and abuse investigations, audits, investigations, inspections,
licensure or permitting, government programs, etc.); |
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* For judicial and
administrative proceedings and law enforcement purposes (e.g., in
response to a warrant, subpoena or court order; by providing PHI to
coroners, medical examiners and funeral directors to locate missing
persons, identify deceased persons or determine cause of death); |
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* For workers'
compensation purposes (e.g., we may disclose your PHI if you have
claimed health benefits for a work-related injury or illness); |
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* For intelligence,
counterintelligence or other national security purposes (e.g., Veterans
Affairs, U.S. military command, other government authorities or foreign
military authorities may require us to release PHI about you); |
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* For organ and tissue
donation (e.g., if you are an organ donor we may release your PHI to
organizations that handle organ, eye or tissue procurement, donation and
transplantation); |
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* For research projects
approved by an Institutional Review Board or a privacy board to ensure
confidentiality (e.g., if the researcher will have access to your PHI
because involved in your clinical care, we will ask you to sign an
Authorization); |
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* To create a collection
of information that is �de-identified� (e.g., it does not personally
identify you by name, distinguishing marks or otherwise and no longer
can be connected to you); |
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* To family members,
friends and others, but only if you verbally give permission; we give
you an opportunity to object and you do not; we reasonably assume, based
on our professional judgment and the surrounding circumstances, that you
do not object (e.g., you bring someone with you into the operatory or
exam room during treatment or into the conference area when we are
discussing your PHI); we reasonably infer that it is in your best
interest (e.g., to allow someone to pick up your records because they
knew you were our patient and you asked them in writing with your
signature to do so); or it is an emergency situation involving you or
another person (e.g., your minor child or ward) and, respectively, you
cannot consent to your care because you are incapable of doing so or you
cannot consent to the other person's care because, after a reasonable
attempt, we have been unable to locate you. In these emergency
situations we may, based on our professional judgment and the
surrounding circumstances, determine that disclosure is in the best
interests of you or the other person, in which case we will disclose
PHI, but only as it pertains to the care being provided and we will
notify you of the disclosure as soon as possible after the care is
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Minimum Necessary Rule Our staff will not use or access your PHI
unless it is necessary to do their jobs (e.g., doctors uninvolved in your
care will not access your PHI; ancillary clinical staff caring for you will
not access your billing information; billing staff will not access your PHI
except as needed to complete the claim form for the latest visit; janitorial
staff will not access your PHI). Also, we disclose to others outside our
staff only as much of your PHI as is necessary to accomplish the recipient's
lawful purposes. For example, we may use and disclose the entire contents of
your medical record:
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* To you (and your legal
representatives as stated above) and any one else you list on a Consent
or Authorization to receive a copy of your records; |
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* To health-care
providers for treatment purposes (e.g. making diagnosis and treatment
decisions or agreeing with prior recommendations in the medical record);
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* To the U.S. Department
of Health and Human Services (e.g., in connection with a HIPAA
complaint); |
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* To others as required
under federal or Florida law; |
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* To our privacy officer
and others as necessary to resolve your complaint or accomplish your
request under HIPAA (e.g., clerks who copy records need access to your
entire medical record). |
In accordance with the law, we presume that requests for disclosure of PHI
from another Covered Entity (as defined in HIPAA) are for the minimum
necessary amount of PHI to accomplish the requester's purpose. Our privacy
officer will individually review unusual or non-recurring requests for PHI
to determine the minimum necessary amount of PHI and disclose only that. For
non-routine requests or disclosures, the Plan's Privacy Officer will make a
minimum necessary determination based on, but not limited to, the following
factors:
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* The amount of
information being disclosed; |
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* The number of
individuals or entities to whom the information is being disclosed; |
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* The importance of the
use or disclosure; |
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* The likelihood of
further disclosure; |
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* Whether the same
result could be achieved with de-identified information; |
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* The technology
available to protect confidentiality of the information; and
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* The cost to implement
administrative, technical and security procedures to protect
confidentiality. |
If we believe that a request from others for disclosure of your entire
medical record is unnecessary, we will ask the requester to document why
this is needed, retain that documentation and make it available to you upon
request.
Incidental Disclosure Rule We will take reasonable administrative,
technical and security safeguards to ensure the privacy of your PHI when we
use or disclose it (e.g., we require employees to talk softly when
discussing PHI with you, we use computer passwords and change them
periodically [e.g., when an employee leaves us], we allow access to areas
where PHI is stored or filed only when we are present to supervise and
prevent unauthorized access).
Business Associate Rule Business Associates and other third parties
(if any) that receive your PHI from us will be prohibited from re-disclosing
it unless required to do so by law or you give prior express written consent
to the re-disclosure. Nothing in our Business Associate agreement will allow
our Business Associate to violate this re-disclosure prohibition.
Super-confidential Information Rule If we have PHI about you
regarding HIV testing, alcohol or substance abuse diagnosis and treatment,
or psychotherapy and mental health records (super-confidential information
under the law), we will not disclose it under the General or Health-care
Treatment, Payment and Operations Rules (see above) without you first
signing and properly completing our Consent form (i.e., you specifically
must initial the type of super-confidential information we are allowed to
disclose). If you do not specifically authorize disclosure by initialing the
super-confidential information, we will not disclose it unless authorized
under the Special Rules (see above) (e.g., we are required by law to
disclose it). If we disclose super-confidential information (either because
you have initialed the Consent form or the Special Rules authorize us to do
so), we will comply with state and federal law that requires us to warn the
recipient in writing that re-disclosure is prohibited.
Changes to Privacy Policies Rule We reserve the right to change our
privacy practices (by changing the terms of this Notice) at any time as
authorized by law. The changes will be effective immediately upon us making
them. They will apply to all PHI we create or receive in the future, as well
as to all PHI created or received by us in the past (i.e., to PHI about you
that we had before the changes took effect). If we make changes, we will
post the changed Notice, along with its effective date, in our office. Also,
upon request, you will be given a copy of our current Notice.
Authorization Rule We will not use or disclose your PHI for any
purpose or to any person other than as stated in the rules above without
your signature on a specifically worded, written Authorization form (not a
Consent or an Acknowledgement). If we need your Authorization, we must
obtain it on our Authorization form, which is separate from any Consent or
Acknowledgment we may have obtained from you. We will not condition
treatment on whether you sign the Authorization (or not).
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
If you got this Notice via
e-mail or web-site, you have the right to get, at any time, a paper copy
by asking our privacy officer. Also, you have the following additional
rights regarding PHI we maintain about you:
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| To Inspect and Copy
You have the right to see and get a copy of your PHI including, but not
limited to, medical and billing records by submitting a written request
to our privacy officer on our Request to Inspect, Copy or Summarize
form. Original records will not leave the premises, will be available
for inspection only during our regular business hours, and only if our
privacy officer is present at all times. You may ask us to give you the
copies in a format other than photocopies (and we will do so unless we
determine that it is impracticable) or ask us to prepare a summary in
lieu of the copies. We may charge you a fee not to exceed Florida law to
recover our costs (including postage, supplies and staff time as
applicable, but excluding staff time for search and retrieval ) to
duplicate or summarize your PHI. We will not condition release of the
copies or summary on payment of your outstanding balance for
professional services (if you have one), but we may condition release of
the copies or summary on payment of the copying fees. We will respond to
requests in a timely manner, without delay for legal review, in less
than thirty days if submitted in writing on our form or otherwise, and
in ten business days or less if malpractice litigation or pre-suit
production is involved. We may deny your request in certain limited
circumstances (e.g., we do not have the PHI, it came from a confidential
source, etc). If we deny your request, you may ask for a review of that
decision. If required by law, we will select a licensed health-care
professional (other than the person who denied your request initially)
to review the denial and we will follow his or her decision. If we
select a licensed health-care professional who is not affiliated with
us, we will ensure a Business Associate agreement is executed that
prevents re-disclosure of your PHI without your consent by the outside
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To Request Amendment / Correction If another doctor involved in your
care tells us in writing to change your PHI, we will do so as expeditiously
as possible upon receipt of the changes and will send you written
confirmation that we have made the changes. If you think PHI we have about
you is incorrect, or that something important is missing from your records,
you may ask us to amend or correct it (so long as we have it) by submitting
a Request for Amendment / Correction form to our privacy officer. We
normally will act on your request within 60 days from receipt, but we may
extend our response time (within the 60-day period) no more than once and by
no more than 30 days, in which case we will notify you in writing why and
when we will be able to respond. If we grant your request, we will let you
know within five business days, make the changes by noting (not deleting)
what is incorrect or incomplete and adding to it the changed language, and
send the changes within 5 business days to persons you ask us to and persons
we know may rely on incorrect or incomplete PHI to your detriment (or
already have). We may deny your request under certain circumstances (e.g.,
it is not in writing, it does not give a reason why you want the change, we
did not create the PHI you want changed (and the entity that did can be
contacted), it was compiled for use in litigation, or we determine it is
accurate and complete). If we deny your request, we will (in writing within
5 business days) tell you: why and how to file a complaint with us if you
disagree, that you may submit a written disagreement with our denial (and we
may submit a written rebuttal and give you a copy of it), that you may ask
us to disclose your initial request and our denial when we make future
disclosures of PHI pertaining to your request, and that you may complain to
us and the U.S. Department of Health and Human Services.
To an Accounting of
Disclosures You may ask us for a list of those who got your PHI from
us by submitting a Request for Accounting of Disclosures form to us. The
list will not cover some disclosures (e.g. PHI given to you, given to
your legal representative, given to others for treatment, payment or
health-care-operations purposes). Your request must state in what form
you want the list (e.g., paper or electronically) and the time period
you want us to cover, which may be up to but no more than the last six
years (excluding dates before April 14, 2003). If you ask us for this
list more than once in a 12-month period, we may charge you a
reasonable, cost-based fee to respond, in which case we will tell you
the cost before we incur it and let you choose if you want to withdraw
or modify your request to avoid the cost.
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To Request Restrictions
You may ask us to limit how your PHI is used and disclosed (i.e. in
addition to our rules as set forth in this Notice) by submitting a
written Request for Restrictions on Use / Disclosure form to us (e.g.,
you may not want us to disclose your surgery to family members or
friends involved in paying for our services or providing your home
care). If we agree to these additional limitations, we will follow them
except in an emergency where we will not have time to check for
limitations. Also, in some circumstances we may be unable to grant your
request (e.g., we are required by law to use or disclose your PHI in a
manner that you want restricted; you signed an Authorization form, which
you may revoke, that allows us to use or disclose your PHI in the manner
you want restricted; in an emergency).
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| To Request Alternative
Communications You may ask us to communicate with you in a different
way or at a different place by submitting a written Request for
Alternative Communication form to us. We will not ask you why and we
will accommodate all reasonable requests (including, e.g., to send
appointment reminders in closed envelopes rather than by postcards, to
send your PHI to a post office box instead of your home address, to
communicate with you at a telephone number other than your home number).
You must tell us the alternative means or location you want us to use
and explain to our satisfaction how payments to us will be made if we
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To Complain or Get More Information We will follow our rules as set
forth in this Notice. If you want more information or if you believe your
privacy rights have been violated (e.g., you disagree with a decision of
ours about inspection / copying, amendment / correction, accounting of
disclosures, restrictions or alternative communications), we want to make it
right. We never will penalize you for filing a complaint. To do so, please
file a formal, written complaint within 180 days with:
The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Ave., S.W.
Washington, D.C. 20201
(877) 696-6775 (toll free)
Or, submit a written complaint form to us at the following address:
Dr. Karina Ottley
8117 Navarre Pkwy
Navarre, FL 32566
850-939-0757
Karina@OttleySmiles.com
You may get your complaint form
by calling our privacy officer.
These privacy practices will be effective April 14, 2003, and will remain in
effect until we replace them as specified above.
If you wish to have a paper copy of this Notice, please feel free to print
it from this site or request a copy the next time you are in the office.
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