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How will we use or disclose your
information? Here are a few examples (for more detail please refer
to the Notice of Privacy Practices available at the front desk):
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For medical treatment
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To obtain payment for our services
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For appointment and patient recall
reminders
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To run our practice more efficiently
& ensure
all our patients receive quality care
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To avert a serious threat to health or
safety
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In emergency situations
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For workers compensation programs
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In response to certain requests
arising out of lawsuits or other disputes
If you believe your privacy rights have been
violated, you may file a complaint with the practice or with the Secretary
of the Department of Health and Human Services. To file a complaint
with the practice, contact our Business Manager. All complaints must
be submitted in writing. You will not be penalized for filing a
complaint.
You have certain rights regarding the
information we maintain about you. These rights include:
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The right to inspect and copy
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The right to amend
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The right to an accounting of disclosures
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The right to request restrictions
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The right to a paper copy of this notice
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The right to request confidential
communications
This information is made
available on request by a patient
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 APPLIES
TO ALL OF THE RECORDS OF YOUR CARE GENERATED BY THE PRACTICE, WHETHER MADE
BY THE PRACTICE OR AN ASSOCIATED FACILITY.
This notice describes our Practices
policies, which extend to:
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Any
health care professional authorized to enter information into your chart
(physicians, PAs, RNs, etc.)
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All areas of the Practice (front desk,
administration, billing and collection, etc.);
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All employees, staff and other personnel
that work for or with our Practice;
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Our business associates
Our practice provides this Notice to comply
with the Privacy Regulations issued by the Department of Health and Human
Services in accordance with the Health Insurance Portability and
Accountability Act of 1996 (HIPAA).
OUR THOUGHTS ABOUT YOUR PROTECTED HEALTH
INFORMATION:
We understand that your medical information
is personal to you, and we are committed to protecting the information
about you. As our patient, we create paper and electronic medical
records about your health, our care for you, and the services and/or items
we provide to you as our patient. We need this record to provide for
your care and to comply with certain legal requirements.
We are required by law to:
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Make sure that the protected health information about you is kept
private;
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Provide you with a Notice of our Privacy
Practices and your legal rights with respect to protected health
information about you; and
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Follow the conditions of the Notice that is
currently in effect.
HOW WE MAY USE AND DISCLOSE MEDICAL
INFORMATION ABOUT YOU.
The following categories describe
different ways that we use and disclose protected health information that
we have and share with others. Each category of uses or disclosures
provides a general explanation and provides some examples of uses.
Not every use or disclosure in a category is either listed or actually in
place. The explanation is provided for your general information
only.
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Medical
Treatment. We use previously given medical information about
you to provide you with current or prospective medical treatment or
services. Therefore we may, and most likely will, disclose medical
information about you to doctors, nurses, technicians, medical students,
or hospital personnel who are involved in taking care of you. For
example, a doctor to whom we refer you for ongoing or further care may
need your medical record. Different areas of the Practice also may
share medical information about you including your record(s),
prescriptions, requests of lab work and x-rays. We may also discuss your
medical information with you to recommend possible treatment options or
alternatives that may be of interest to you. We also may disclose
medical information about you to people outside the Practice who may be
involved in your medical care after you leave the Practice; this may
include your family members, or other personal representatives authorized
by you or by a legal mandate (a guardian or other person who has been
named to handle your medical decisions, should you become incompetent).
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Payment.
We may use and disclose medical information about you for services and
procedures so they may be billed and collected from you, an insurance
company, or any other third party. For example, we may need to give
your health care information about treatment you received at the Practice
to obtain payment or reimbursement for the care. We may also tell
your health plan and/or referring physician about a treatment you are
going to receive to obtain prior approval or to determine whether your
plan will cover the treatment, to facilitate payment of a referring
physician, or the like. If you are a full-time college student under the
age of 24 and carried under your parents insurance, we may discuss your
treatment with the parent in order to collect payment.
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Health
Care Operations. We may use and disclose medical information
about you so that we can run our Practice more efficiently and make sure
that all of our patients receive quality care. These uses may include
reviewing our treatment and services to evaluate the performance of our
staff, deciding what additional services to offer and where, deciding what
services are not needed, and whether certain new treatments are effective.
We may also disclose information to doctors, nurses, technicians, medical
students, and other personnel for review and learning purposes. We may
also combine the medical information we have with medical information from
other Practices to compare how we are doing and see where we can make
improvements in the care and services we offer. We may remove information
that identifies you from this set of medical information so others may use
it to study health care and health care delivery without learning who the
specific patients are.
We may also use or disclose information
about you for internal or external utilization review and/or quality
assurance, to business associates for purposes of helping us to comply
with our legal requirements, to auditors to verify our records, to billing
companies to aid us in this process and the like. We shall endeavor,
at all times when business associates are used, to advise them of their
continued obligation to maintain the privacy of your medical records.
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Appointment
and Patient Recall Reminders. We may ask that you sign in
writing at the Receptionists' Desk, a "Sign In" log on the day of your
appointment with the Practice. We may use & disclose medical
information to contact you as a reminder that you have an appointment for
medical care with the Practice or that you are due to receive periodic
care from the Practice. This contact may be by phone, in writing,
e-mail, or otherwise.
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Emergency
Situations. In addition, we may disclose medical information
about you to an organization assisting in a disaster relief effort or in
an emergency situation so that your family can be notified about your
condition, status and location.
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Research.
Under certain circumstances, we may use and disclose medical information
about you for research purposes regarding medications, efficiency of
treatment protocols and the like. All research projects are subject to an
approval process, which evaluates a proposed research project and its use
of medical information. Before we use or disclose medical
information for research, the project will have been approved through this
research approval process. We will obtain an Authorization from you
before using or disclosing your individually identifiable health
information unless the authorization requirement has been waived. If
possible, we will make the information non-identifiable to a specific
patient. If the information has been sufficiently de-identified, an
authorization for the use or disclosure is not required.
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Required
By Law. We will disclose medical information about you when
required to do so by federal, state or local law.
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To
Avert a Serious Threat to Health or Safety. We may use and
disclose medical information about you when necessary to prevent a serious
threat either to your specific health and safety or the health and safety
of the public or another person. Any disclosure, however, would only be to
someone able to help prevent the threat.
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Organ
and Tissue Donation. If you are an organ donor, we may release
medical information to organizations that handle organ procurement or
organ, eye or tissue transplantation or to an organ donation bank, as
necessary to facilitate organ or tissue donation and transplantation.
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Workers'
Compensation. We may release medical information about you
for workers' compensation or similar programs. These programs provide
benefits for work-related injuries or illness.
Public
Health Risks. Law or public policy may require us to disclose
medical information about you for public health
activities. These activities generally include the following:
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to prevent or control disease, injury or disability;
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to report births and deaths;
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to report child abuse or neglect
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to report reactions to medications or problems
with products;
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to notify people of recalls of products they may
be using;
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to notify a person who may have been exposed to a disease or may be at
risk for contracting or
spreading a disease or condition;
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to notify the appropriate government authority if
we believe a patient has been the victim of abuse, neglect or domestic violence.
We will only make this disclosure if you agree or when required or authorized by
law.
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Investigation
and Government Activities. We may disclose medical information to
a local, state or federal agency for activities authorized by law. These
oversight activities include, for example, audits, investigations,
inspections, and licensure. These activities are necessary for the payer,
the government and other regulatory agencies to monitor the health care
system, government programs, and compliance with civil rights laws.
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Lawsuits
and Disputes. If you are involved in a lawsuit or a dispute, we
may disclose medical information about you in response to a court or
administrative order. We may also disclose medical information about you
in response to a subpoena, discovery request, or other lawful process by
someone else involved in the dispute. We shall attempt in these
cases to tell you about the request so that you may obtain an order
protecting the information requested if you so desire. We may also
use such information to defend ourselves or any member of our Practice in
any actual or threatened action.
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Law
Enforcement. We may release medical information if asked to do so
by law enforcement official:
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In response to a court order, subpoena, warrant,
summons or similar process;
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To identify or locate a
suspect, fugitive, material witness, or missing person;
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About the victim of a crime
if, under certain limited circumstances, we are unable to obtain the person's agreement;
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About a death we believe may
be the result of criminal conduct;
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About criminal conduct at
the Practice; and
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In emergency circumstances
to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the
crime.
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Coroners,
Medical Examiners and Funeral Directors. We may release medical
information to a coroner or medical examiner. This may be necessary, for
example, to identify a deceased person or determine the cause of death. We
may also release medical information about patients of the Practice to
funeral directors as necessary to carry out their duties.
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Inmates.
If you are an inmate of a correctional institution or under the custody of
a law enforcement official, we may release medical information about you
to the correctional institution or law enforcement official. This release
would be necessary (1) for the institution to provide you with health
care; (2) to protect your health and safety or the health and safety of
others; or (3) for the safety and security of the correctional
institution.
CHANGES TO THIS NOTICE
We
reserve the right to change this notice at any time. We reserve the
right to make the revised or changed notice effective for medical
information we already have about you as well as any information we may
receive from you in the future. We will post a copy of the current notice
in the Practice. The notice will contain on the first page, in the top
right-hand corner, the date of last revision and effective date. In
addition, each time you visit the Practice for treatment or health care
services you may request a copy of the current notice in effect.
COMPLAINTS
If you believe your privacy rights have been
violated, you may file a complaint with the Practice or with the Secretary
of the Department of Health and Human Services. To file a complaint with
the practice, contact our office manager, who will direct you on how to
file an office complaint. All complaints must be submitted in
writing, and all complaints shall be investigated, without repercussion to
you. Our office manager can be reached at 610-667-4455. You will not be
penalized for filing a complaint.
OTHER USES OF MEDICAL INFORMATION.
Other uses and disclosures of medical information not covered by this
notice or the laws that apply to us will be made only with your written
permission, unless those uses can be reasonably inferred from the intended
uses above. If you have provided us with your permission to use or
disclose medical information about you, you may revoke that permission, in
writing, at any time. If you revoke your permission, we will no longer use
or disclose medical information about you for the reasons covered by your
written authorization. You understand that we are unable to
take back any disclosures we have already made with your permission, and
that we are required to retain our records of the care that we provided to
you.
PATIENT RIGHTS
THIS SECTION DESCRIBES
YOUR RIGHTS AND THE OBLIGATIONS OF THIS PRACTICE REGARDING THE USE AND
DISCLOSURE OF YOUR MEDICAL INFORMATION.
You have the following rights regarding
medical information we maintain about you:
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Right
to Inspect and Copy. You have the right to inspect and copy
medical information that may be used to make decisions about your care.
This includes your own medical and billing records, but does not include
psychotherapy notes. Upon proof of an appropriate legal
relationship, records of others related to you or under your care
(guardian or custodial) may also be disclosed. To inspect and copy
your medical record, you must submit your request in writing to our
Compliance Officer. Ask the front desk person for the name of the
Compliance Officer. If you request a copy of the information, we may
charge a fee for the costs of copying, mailing or other supplies (tapes,
disks, etc.) associated with your request.
We may deny your request to inspect and copy
in certain very limited circumstances. If you are denied access to medical
information, you may request that our Compliance Committee review the
denial. Another licensed health care professional chosen by the Practice
will review your request and the denial. The person conducting the review
will not be the person who denied your request. We will comply with the
outcome and recommendations from that review.
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Right
to Amend. If you feel that the medical information we have about
you in your record is incorrect or incomplete, then you may ask us to
amend the information, following the procedure below. You have the
right to request an amendment for as long as the Practice maintains your
medical record. To request an amendment, your request must be submitted in
writing, along with your intended amendment and a reason that supports
your request to amend. The amendment must be dated and signed by you
and notarized.
We may deny your
request for an amendment if it is not in writing or does not include a
reason to support the request. In addition, we may deny your request if
you ask us to amend information that:
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Was
not created by us, unless the person or entity that created the
information is no longer available to make the amendment;
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Is not part of the medical information kept
by or for the Practice;
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Is not part of the information which you
would be permitted to inspect and copy; or
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Is inaccurate and incomplete.
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Right to an Accounting of Disclosures. You have the right to
request an "accounting of disclosures." This is a list of the disclosures we made of medical information
about you to others. To request this list, you must submit your request in
writing. Your request must state a time period not longer than six (6)
years back and may not include dates before April 14, 2003 (or the actual
implementation date of the HIPAA Privacy Regulations). Your request
should indicate in what form you want the list (for example, on paper, electronically). We will notify you of the cost
involved and you may choose to withdraw or modify your request at that
time before any costs are incurred.
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Right to Request Restrictions. You have the right to request a
restriction or limitation on the medical
information we use or disclose about you for treatment, payment or
health care operations. You also have the right to request a limit on the
medical information we disclose about you to someone who is involved in
your care or the payment for your care (a family member or friend). For
example, you could ask that we not use or disclose information about a
particular treatment you received.
We are not required
to agree to your request and we may not be able to comply with your
request. If we do agree, we will comply with your request except
that we shall not comply, even with a written request, if the information
is excepted from the consent requirement or we are otherwise required to
disclose the information by law.
To request
restrictions, you must make your request in writing. In your request, you
must indicate:
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what information you want to limit;
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whether you want to limit our use,
disclosure or both; and
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to whom you want the limits to apply, (e.g.,
disclosures to your children, parents, spouse, etc.)
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Right
to Request Confidential Communications. You have the right to
request that we communicate with you about medical matters in a certain way or at a certain
location. For example, you can ask that we only contact
you at work or by mail, that we not leave voice mail or e-mail, or
the like.
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To request
confidential communications, you must make your request in writing. We
will not ask you the reason for your request. We will accommodate
all reasonable requests. Your request must specify how or where you
wish us to contact you.
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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 this notice at any
time. Even if you have agreed to receive this notice electronically, you
are still entitled to a paper copy of this notice.
Mansoor
Madani DMD
PATIENT CONSENT FORM
Our Notice of Privacy Practices provides
information about how we may use and disclose protected health information
about you. The Notice contains a Patient Rights section describing
your rights under the law. You have the right to review our Notice
before signing this Consent. The terms of our Notice may change. If
we change our Notice, you may obtain a revised copy by contacting our
office.
You have the right to request that we
restrict how protected health information about you is used or disclosed
for treatment, payment or health care operations. We are not required to
agree to this restriction, but if we do, we shall honor that agreement.
By signing this form, you consent to our use
and disclosure of protected health information about you for treatment,
payment and health care operations. You have the right to revoke this
Consent, in writing, signed by you. However, such a revocation shall
not affect any disclosures we have already made in reliance on your prior
Consent. The Practice provides this form to comply with the Health
Insurance Portability and Accountability Act of 1996 (HIPAA).
The patient understands that:
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Protected
health information may be disclosed or used for treatment, payment
or
health care operations.
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All other disclosures by the practice will
require specific authorization by you unless required by law.
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The Practice has a Notice of Privacy
Practices and that the patient has the opportunity to review this Notice
and receive a copy.
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The Practice reserves the right to change
the Notice of Privacy Policies. The new policy will be posted in the lobby
and on the web site.
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The
patient has the right to restrict the uses of their information used
for
treatment, payment or operations, but the Practice does not
have to agree to those restrictions.
Make your appointment online now
for consultation & evaluation!
1-800-206-2000
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