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.
The Health Insurance Portability & Accountability Act of 1996 (HIPPA) requires all health care records and other individually identifiable health information used or disclosed to us in any form, whether electronically, paper, or orally, to be kept confidential. This federal law gives you, the patient, significant new rights to understand and control how your health information is used. HIPPA provides penalties for covered entities that misuse personal health information. As required by law, we have prepared this explanation of how we are required to maintain the privacy of our 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 healt6hcare operations.
o Treatment means providing, coordinating, or managing healthcare & related services by one or more health care providers, for example, we may need to share information with other healthcare providers or specialists involved in the continuation of your care.
o Payment means such activities as obtaining reimbursement for services, confirming coverage, billing, or collection activities & utilization review. For example, we may disclose treatment information when b8illing a dental plan for services.
o Healthcare Operations include the busin3ess aspects of running our practice. For example, patient information may be used for training purposes or quality assessment.
Unless you request otherwise, we may use or disclose health information to a family member, friend, personal representative, or other individual to the extent necessary to help with your healthcare or with payment for your healthcare. In the event of an emergency or your incapacity, we will use our professional judgement in disclosing only the protected health information necessary to facilitate needed care. In addition, we may use our confidential information to remind you of appointments by sending reminder text messages and/or leaving messages at home and/or work. Your protected health information may also be our office to recommend treatment alternatives or to provide you with information about oversight activities, judicial or administrative proceedings, in response to a subpoena or court order, to military authorities of Armed Forces personnel, to federal officials or lawful intelligence, counterintelligence, and other national security activities, to correctional institutions or law enforcement officials and/or to report suspected abuse, neglect, or domestic violence. 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.
You have certain rights regarding protected health information, which you may exercise by presenting a written request to our front office at the practice address listed below:
o The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosure 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.
o The right to request to receive confidential communications of protected health information from us by alternative means or at alternative locations.
o The right to access, inspect, and comply your protected health information, with limited exceptions. A reasonable fee may be assessed.
o The right to receive an accounting of disclosures of protected health info5rmation made outside of treatment, payment, or healthcare operations, or based on your previous authorization.
o The right to obtain a paper copy of this notice from us upon request, even if you have agreed to receive the notice electronically.
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 January 1, 2019, and we are required to abide by the terms of the Notice of Privacy Practice currently in effect. We reserve the right to change the terms of our Notice of Privacy Practice and to make the new notice provisions effective for all protected health information that we maintain. Revisions to our Notice of Privacy Practice will be posted on the effective date and you may request a written copy of the revised notice from the office.
You have the right to file a formal written complaint with us at the address below, or with the Department of Health & Human Services, Offices of Civil Rights, in the event you feel your privacy rights have been violated. We will not retaliate against you for filing a complaint.
For more information about our privacy practices: For more information about HIPPA or to file a complaint:
Tristan Galloway DDS PLLC The U.S. Department of Health & Human Services
716 16th Avenue South Office of Civil Rights
Nampa, Idaho 83651 (208) 466-4261 200 Independence Avenue, S.W.
Washington, D.C. 20201 (877)696-6775
I have read the HIPPA Notice of Privacy Practices: Date:____________________________________
Print Name:______________________________ Signature:_________________________________