Notice of Our Privacy Practices
Dr. Roger Pardon, DDS
1828 Bay Scott Circle, #108
Naperville , IL 60540
630-369-6000
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 PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.
Our Legal Duty
We are required by applicable federal and state laws to maintain the
privacy of your protected health information. We are also required to
give you this notice about our privacy practices, our legal duties, and
your rights concerning your protected health information. We must follow
the privacy practices that are described in this notice while it is in
effect. This notice takes effect April 14th, 2003, 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 that 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 protected
health information that we maintain, including medical information we
created or received before we made the changes.
You may request a copy of our notice (or any subsequent revised 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 Protected Health Information
We will use and disclose your protected health information about you
for treatment, payment, and health care operations. Following are examples
of the types of uses and disclosures of your protected health care information
that may occur. These examples are not meant to be exhaustive, but to
describe the types of uses and disclosures that may be made by our office.
Treatment:
We will use and disclose your protected
health information to provide, coordinate or manage your health care
and any related services. This includes the coordination or management
of your health care with a third party. For example, we would disclose
your protected health information, as necessary, to a home health agency
that provides care to you. We will also disclose protected health information
to other physicians who may be treating you. For example, your protected
health information may be provided to a physician to whom you have
been referred to ensure that the physician has the necessary information
to diagnose or treat you.
In addition, we may disclose your protected health information from time
to time to another physician or health care provider (e.g., a specialist
or laboratory) who, at the request of your physician, becomes involved
in your care by providing assistance with your health care diagnosis
or treatment to your physician.
Payment:
Your protected health information will be
used, as needed, to obtain payment for your health care services. This
may include certain activities that your health insurance plan may
undertake before it approves or pays for the health care services we
recommend for you, such as: making a determination of eligibility or
coverage for insurance benefits, reviewing services provided to you
for protected health necessity, and undertaking utilization review
activities. For example, obtaining approval for a hospital stay may
require that your relevant protected health information be disclosed
to the health plan to obtain approval for the hospital admission.
Health Care Operations:
We may use or disclose, as
needed, your protected health information in order to conduct certain
business and operational activities. These activities include, but
are not limited to, quality assessment activities, employee review
activities, training of students, licensing, and conducting or arranging
for other business activities.
For example, we may use a sign-in sheet at the registration desk where
you will be asked to sign your name. We may also call you by name in
the waiting room when your doctor is ready to see you. We may use or
disclose your protected health information, as necessary, to contact
you by telephone or mail to remind you of your appointment.
We will share your protected health information with third party "business
associates" that perform various activities (e.g., billing, transcription
services) for the practice. Whenever an arrangement between our office
and a business associate involves the use or disclosure of your protected
health information, we will have a written contract that contains terms
that will protect the privacy of your protected health information.
We may use or disclose your protected health information, as necessary,
to provide you with information about treatment alternatives or other
health-related benefits and services that may be of interest to you.
We may also use and disclose your protected health information for other
marketing activities. For example, your name and address may be used
to send you a newsletter about our practice and the services we offer.
We may also send you information about products or services that we believe
may be beneficial to you. You may contact us to request that these materials
not be sent to you.
Uses and Disclosures Based On Your Written Authorization:
Other
uses and disclosures of your protected health information will be made
only with your authorization, unless otherwise permitted or required
by law as described below.
You may give us written authorization to use your protected 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 affect
any use or disclosures permitted by your authorization while it was in
effect. Without your written authorization, we will not disclose your
health care information except as described in this notice.
Others Involved in Your Health Care: Unless you object, we may disclose
to a member of your family, a relative, a close friend or any other person
you identify, your protected health information that directly relates
to that person's involvement in your health care. If you are unable to
agree or object to such a disclosure, we may disclose such information
as necessary if we determine that it is in your best interest based on
our professional judgment. We may use or disclose protected health information
to notify or assist in notifying a family member, personal representative
or any other person that is responsible for your care of your location,
general condition or death.
Marketing:
We may use your protected health information to contact you
with information about treatment alternatives that may be of interest
to you. We may disclose your protected health information to a business
associate to assist us in these activities. Unless the information is
provided to you by a general newsletter or in person or is for products
or services of nominal value, you may opt out of receiving further such
information by telling us using the contact information listed at the
end of this notice.
Research; Death; Organ Donation:
We may use or disclose your protected health information for research purposes in limited circumstances. We
may disclose the protected health information of a deceased person to
a coroner, protected health examiner, funeral director or organ procurement
organization for certain purposes.
Public Health and Safety:
We may disclose your protected health information
to the extent necessary to avert a serious and imminent threat to your
health or safety, or the health or safety of others. We may disclose
your protected health information to a government agency authorized to
oversee the health care system or government programs or its contractors,
and to public health authorities for public health purposes.
Health Oversight:
We may disclose protected health information to a health
oversight agency for activities authorized by law, such as audits, investigations
and inspections. Oversight agencies seeking this information include
government agencies that oversee the health care system, government benefit
programs, other government regulatory programs and civil rights laws.
Abuse or Neglect:
We may disclose your protected health information to
a public health authority that is authorized by law to receive reports
of child abuse or neglect. In addition, we may disclose your protected
health information if we believe that you have been a victim of abuse,
neglect or domestic violence to the governmental entity or agency authorized
to receive such information. In this case, the disclosure will be made
consistent with the requirements of applicable federal and state laws.
Food and Drug Administration:
We may disclose your protected health information
to a person or company required by the Food and Drug Administration to
report adverse events, product defects or problems, biologic product
deviations; to track products; to enable product recalls; to make repairs
or replacements; or to conduct post marketing surveillance, as required.
Criminal Activity:
Consistent with applicable federal and state laws,
we may disclose your protected health information, if we believe that
the use or disclosure is necessary to prevent or lessen a serious and
imminent threat to the health or safety of a person or the public. We
may also disclose protected health information if it is necessary for
law enforcement authorities to identify or apprehend an individual.
Required by Law:
We may use or disclose your protected health information
when we are required to do so by law. For example, we must disclose your
protected health information to the U.S. Department of Health and Human
Services upon request for purposes of determining whether we are in compliance
with federal privacy laws. We may disclose your protected health information
when authorized by workers' compensation or similar laws.
Process and Proceedings:
We may disclose your protected health information
in response to a court or administrative order, subpoena, discovery request
or other lawful process, under certain circumstances. Under limited circumstances,
such as a court order, warrant or grand jury subpoena, we may disclose
your protected health information to law enforcement officials.
Law Enforcement:
We may disclose limited information to a law enforcement
official concerning the protected health information of a suspect, fugitive,
material witness, crime victim or missing person. We may disclose the
protected health information of an inmate or other person in lawful custody
to a law enforcement official or correctional institution under certain
circumstances. We may disclose protected health information where necessary
to assist law enforcement officials to capture an individual who has
admitted to participation in a crime or has escaped from lawful custody.
Patient Rights
Access:
You have the right to look at or get copies of your protected
health information, with limited exceptions. You must make a request
in writing to the contact person listed herein to obtain access to your
protected health information. 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 $25.00 for each page or $10.00 per hour to
locate and copy your protected health information, and postage if you
want the copies mailed to you. If you prefer, we will prepare a summary
or an explanation of your protected 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.
Accounting of Disclosures:
You have the right to receive a list of instances
in which we or our business associates disclosed your protected health
information for purposes other than treatment, payment, health care operations
and certain other activities after April 14, 2003. After April 14, 2009,
the accounting will be provided for the past six (6) years. We will provide
you with the date on which we made the disclosure, the name of the person
or entity to whom we disclosed your protected health information, a description
of the protected health information we disclosed, the reason for the
disclosure, and certain other information. If you request this list more
than once in a 12-month period, we may charge you a reasonable, cost-based
fee for responding to these additional requests. Contact us using the
information listed at the end of this notice for a full explanation of
our fee structure.
Restriction Requests:
You have the right to request that we place additional
restrictions on our use or disclosure of your protected 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). Any agreement
we may make to a request for additional restrictions must be in writing
signed by a person authorized to make such an agreement on our behalf.
We will not be bound unless our agreement is so memorialized in writing.
Confidential Communication:
You have the right to request that we communicate
with you in confidence about your protected health information by alternative
means or to an alternative location. You must make your request in writing.
We must accommodate your request if it is reasonable, specifies the alternative
means or location, and continues to permit us to bill and collect payment
from you.
Amendment:
You have the right to request that we amend your protected
health information. Your request must be in writing, and it must explain
why the information should be amended. We may deny your request if we
did not create the information you want amended or for certain other
reasons. If we deny your request, we will provide you a written explanation.
You may respond with a statement of disagreement to be appended to the
information you wanted amended. If we accept your request to amend the
information, we will make reasonable efforts to inform others, including
people or entities you name, of the amendment and to include the changes
in any future disclosures of that information.
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. Please contact us using
the information listed at the end of this notice to obtain 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 using the information below. If you believe
that we may have violated your privacy rights, or you disagree with a
decision we made about access to your protected health information or
in response to a request you made, you may complain to us using the contact
information below. 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 your complaint with the U.S.
Department of Health and Human Services upon request.
We support your right to protect the privacy of your protected health
information. We will not retaliate in any way if you choose to file a
complaint with us or with the U.S. Department
of Health and Human Services.
Name of Contact Person: Dr. Roger Pardon, DDS
Telephone: 630-369-6000
Address: 1828 Bay Scott Circle, #108, Naperville, IL 60540
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