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THIS NOTICE DESCRIBES HOW HEALTH
INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY. THE
PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
OUR LEGAL DUTY
We are required by applicable federal and state law
to maintain the privacy of your health information.
We are also required to give you this Notice about our
privacy practices, our legal duty, and your rights concerning
your health information. We must follow the privacy
practices that are described in this Notice while it
is in effect. This Notice takes effect 10/15/02, and
will remain in effect until we replace it.
We reserve the right to change our privacy practices
and the terms of this Notice at any time, provided such
changes are permitted by applicable law. We reserve
the right to make the changes in our privacy practices
and the new terms of our Notice effective for all health
information that we maintain, including health information
we created or received before we made the changes. Before
we make a significant change in our privacy policy practices,
we will change this Notice and make the new Notice available
upon request.
You may request a copy of our Notice at any time. For
more information about our privacy practices, or for
additional copies of this Notice, please contact us
using the information listed at the end of this Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for
treatment, payment , and healthcare operations. For
Example:
Treatment: We may use and disclose your health
information to a physician or other healthcare provider
providing treatment to you.
Payment: We may use and disclose your health
information to obtain payment for services we provide
to you.
Healthcare Operations: We may use and disclose
your health information in connection with our healthcare
operations. Healthcare operations include quality assessment
and improvement activities, reviewing the competence
or qualifications of healthcare professionals, evaluating
practitioner and provider performance, conducting training
programs, accreditation, certification, licensing or
credentialing activities.
Your Authorization: In addition to our use of
your health information for treatment, payment or healthcare
operations, you may give us written authorization to
use your health information or to disclose it to anyone
for any purpose. If you give us an authorization, you
may revoke it in writing at any time. Your revocation
will not effect any use or disclosures permitted by
your authorization while it was in effect. Unless you
give us a written authorization, we cannot use or disclose
your health information for any reason except those
described in this Notice.
To Your Family and Friends: We must disclose
your health information to you to notify, as described
in the Patient Rights sections of this Notice. We may
disclose your health information to a family member,
friend or other person to the extent necessary to help
with your healthcare or with payment for your healthcare,
but only if you agree that we may do so.
Persons Involved In Care: We may use or disclose
health information to notify, or assist in the notification
of (including identifying or locating) a family member,
your personal representative or another person responsible
for your care, of your location, your general condition,
or death. If you are present, then prior to use or disclosure
of your health information, we will provide you with
an opportunity to object to such uses or disclosures.
In the event of your incapacity or emergency circumstances,
we will disclose health information based on a determination
using our professional judgement disclosing only health
information that is directly relevant to the person’s
involvement in your healthcare. We will also use our
professional judgement and our experience with common
practice to make reasonable inferences of your best
interest in allowing a person to pick up filled prescriptions,
medical supplies, x-rays, or other similar forms of
health information.
Marketing Health-Related Services: We will not
use your health information for marketing communications
without your written authorization.
Required by Law: We may use or disclose your
health information when we are required to do so by
law.
Abuse or Neglect: We may disclose your health
information to appropriate authorities if we reasonably
believe that you are a possible victim of abuse, neglect,
or domestic violence or the possible victim of other
crimes. We may disclose your health information to the
extent necessary to avert a serious threat to your safety
or the health of safety of others.
National Security: We may disclose to military
authorities the health information of Armed Forces personnel
under certain circumstances. We may disclose to authorized
federal officials health information required for lawful
intelligence, counterintelligence, and other national
security activities. We may disclose to correctional
institution or law enforcement officials having lawful
custody of protected health information of inmate or
patient under certain circumstances.
Appointment Reminders: We may use or disclose
your health information to provide you with appointment
reminders (such as voicemail messages, postcards, or
letters).
PATIENT RIGHTS
Access: You have the right to look at or get copies
of your health information, with limited exceptions. You may
request that we provide copies in a format other than photocopies.
We will use the format you request unless we cannot practicably
do so. (You must make a request in writing to obtain access
to your health information. You may obtain a form to request
access by using the contact information listed at the end
of this Notice. We will charge you a reasonable cost-based
fee for expenses such as copies and staff time. You may also
request access by sending us a letter to the address at the
end of this Notice. If you request copies, we will charge
you $.10 for each page, $30.00, per hour for staff time to
locate and copy your health information, and postage if you
want the copies mailed to you. If you request an alternative
format, we will charge a cost-based fee for providing your
health information in that format. If you prefer, we will
prepare a summary or an explanation of your health information
for a fee. Contact us using the information listed at the
end of this Notice for a full explanation of our fee structure.)
Disclosure Accounting: You have the right to
receive a list of instances in which we or our business
associates disclosed your health information for purposes,
other than treatment, payment, healthcare operations
and certain other activities, for the last 6 years,
but not before April 14, 2003. If you request this accounting
more than once in a 12-month period, we may charge you
a reasonable, cost-based fee for responding to these
additional requests.
Restriction: You have the right to request that
we place additional restrictions on our use or disclosure
of your health information. We are not required to agree
to these additional restrictions, but if we do, we will
abide by our agreement (except in an emergency).
Alternative Communication: You have the right
to request that we communicate with you about your health
information by alternative means or to alternative locations.
(You must make your request in writing.) Your request
must specify the alternative means or location, and
provide satisfactory explanation how payments will be
handled under the alternative means or location you
request.
Amendment: You have the right to request that
we amend your health information. (Your request must
be in writing, and must explain why the information
should be amended.) We may deny your request under certain
circumstances.
Electronic Notice: If you receive this Notice
on our Web site or by electronic mail (e-mail), you
are entitled to receive this Notice in written form.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices
or have questions or concerns, please contact us.
If you are concerned that we may have violated your
privacy rights, or you disagree with a decision we made
about access to your health information or in response
to a request you made to amend or restrict the use or
disclosure of your health information or to have us
communicate with you by alternative means or at alternative
locations, you may complain to us using the contact
information listed at the end of this Notice. You also
may submit a written complaint to the U.S. Department
of Health and Human Services. We will provide you with
the address to file you complaint with the U.S. Department
of Health and Human Services.
Contact Officer: Chrissie, Office Manager
Telephone: 541-754-0600 Fax: 541-758-4282
Address: 2500 NW Century Dr., Corvallis, OR 97330
© 2002 American Dental Association
All Rights Reserved
Reproduction and use of this form by
dentists and their staff is permitted. Any other use,
duplication or distribution of this form by any other
party requires the prior written approval of the American
Dental Association.
In addition to our office Privacy Practices, we also
have an additional Privacy Policy
for our web site.
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