DR. RAYMOND M. KLEIN
NOTICE OF PRIVACY PRACTICES
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.
If you have any questions about this
Notice, please contact Dr. Raymond M. Klein
This Notice of Privacy Practices
describes how we may use and disclose your protected health information to
carry out treatment, payment or health care operations and for other purposes
that are permitted or required by law. It also describes your rights to access
and control your protected health information. "Protected health
information" is information about you, including demographic information,
that may identify you and that relates to your past, present or future physical
or mental health or condition and related health care services.
This Notice describes the privacy
practices of the office of Dr. Raymond M. Klein ..
We are required by law to maintain
the privacy of protected health information and to provide you with notice of
our legal duties and our privacy practices. We are required to abide by the
terms of this Notice of Privacy Practices. We may change the terms of our
notice, at any time. The new notice will be effective for all protected health
information that we maintain at that time. Upon your request, we will provide
you with any revised Notice of Privacy Practices by accessing our website www.dr4gums.com, calling our office at 707 429-5200 and
requesting that a revised copy be sent to you in the mail, or asking for one at
the time of your next appointment.
1.
Uses and
Disclosures of Protected Health Information.
This section of the Notice
describes rules and procedures for the use and disclosure of protected health
information in our office. By protected health information, we mean any
personally identifiable health information about you
A. Uses and Disclosures of Protected Health Information for Treatment,
Payment, and Health Care Operations.
In order for the our office to
provide good quality care and operate an effective health care system, it is
necessary that we are able to use and disclose your protected health
information for three specific purposes: (1) to provide you treatment; (2) for
us to pay for care you receive or, in some cases, to collect from you or
another payer; and (3) the management of our office for issues like quality
assurance assessments. We refer to these three purposes as: treatment, payment,
and health care operations. They are explained more below.
Under the law, most health care
providers will ask you to sign a consent form to allow them to use your
protected health information for treatment, payment, and health care
operations. If you do not sign this form, they are allowed in most cases to
refuse to give you health care. If you refuse consent we will exercise our
right to refuse treatment if you do not consent to our use of your protected
health information for treatment, payment, and health care operations.)
Following are examples of the
types of uses and disclosures of your protected health care information that our
office is permitted to make to carry out treatment, payment, and health care
operations. These examples are not
meant to be exhaustive, but to describe the types of uses and disclosures involved.
.
Treatment: We will use and
disclose your protected health information to provide, coordinate, or manage
your health care and any related services. For example, we may disclose your protected health information, as necessary, to dentists,
doctors, nurses, and other health care providers, or departments of hospitals,
involved in providing your care. We will also disclose protected health
information to other physicians or dentists who may be treating you. For
example, your protected health information may be provided to a dentist to whom
you have been referred to ensure that the dentist has the necessary information
to diagnose or treat you. This protected information may also be disclosed to
pharmacists who dispense drugs that you are prescribed by dentists or other health
care providers.
Payment: Your protected
health information will be used, as needed, to obtain payment for your health
care services. This applies to the fees that patients are required to pay. It
also applies to those cases in which a third party payer may have an obligation
under law to pay for care in our office. Examples of this are health insurance,
automobile insurance in accident cases, and workers compensation insurance for
workplace injuries or illnesses. We will use your protected health information
to submit to insurance plans and other third party payers for pre-authorization
of benefits or estimates of the extent of coverage for services we expect to
perform for you.
Healthcare Operations: We
may use or disclose your protected health information in order to support the
daily activities related to provision of health care.. These activities include
but are not limited to, quality assessment activities, investigations,
oversight or staff performance reviews, training of employees, students,
licensing, marketing activities, and conducting or arranging for other health
care related activities. Other activities include arranging for legal and
auditing services, business planning and development, customer service, and
general administrative activities. .
B. Uses and Disclosures of
Protected Health Information Based upon Your Written Authorization.
In
general, other uses and disclosures of your protected health information will
be made only with your written authorization, unless otherwise permitted or
required by law, as described below. You may revoke this authorization, at any
time, in writing, except to the extent that our office has taken an action in reliance on the use or
disclosure indicated in the authorization.
C. Other Routine Uses and
Disclosures That May Be Made, Unless You Object.
There are several other routine
uses and disclosures we would generally make, but we will give you an
opportunity to agree or object. If you do object, we will generally not make
them, except in special circumstances.
Others Involved in Your
Healthcare: 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 not present or 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. Finally, we may use or
disclose your protected health information to an authorized public or private
entity to assist in disaster relief efforts and to coordinate uses and
disclosures to family or other individuals involved in your health care.
Emergencies: We may use or
disclose your protected health information in an emergency treatment situation.
If this happens your physician or dentist shall try to obtain your consent as
soon as reasonably practicable after the delivery of treatment. If your dentist
or physician or another physician is required by law to treat you and the
physician has attempted to obtain your consent but is unable to obtain your
consent, he or she may still use or disclose your protected health information
to treat you.
Communication Barriers: We
may use and disclose your protected health information if your dentist or physician
attempts to obtain consent from you but is unable to do so due to substantial
communication barriers and the physician determines, using professional
judgment, that you intend to consent to use or disclosure under the
circumstances.
D. Other Permitted and
Required Uses and Disclosures That May Be Made Without Your Consent,
Authorization or Opportunity to Object.
We may use or disclose your
protected health information in the following situations without your consent
or authorization. These situations include:
Required By Law: We may use
or disclose your protected health information to the extent that the use or
disclosure is required by law or government regulation (including DoD and
military service regulations). The use or disclosure will be made in compliance
with the law or regulation and will be limited to the relevant requirements of
the law or regulation. You will be notified, as required by law or regulation,
of any such uses or disclosures.
Public Health: We may
disclose your protected health information for public health activities and
purposes to a public health authority (including Department of Defense
components engaged in public health activities) that is permitted by law or
government regulations to collect or receive the information. The disclosure
will be made for the purpose of controlling disease, injury or disability. We
may also disclose your protected health information, if directed by the public
health authority, to a foreign government agency that is collaborating with the
public authority. We may also 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, track
products; to enable product recalls; to make repairs or replacements, or to
conduct post marketing surveillance as required.
Communicable Diseases: We
may disclose your protected health information, if authorized by law or
government regulations, to a person who may have been exposed to a communicable
disease or may otherwise be at risk of contracting or spreading the disease or
condition.
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 state Dental Board and
other 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 law enforcement agency or other
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 laws.
Legal Proceedings: We may
disclose protected health information in the course of any judicial or
administrative proceeding, in response to an order of a court, judge, or
administrative tribunal (to the extent such a disclosure is expressly
authorized), in certain conditions in response to a subpoena, discovery request
or other lawful process.
Law Enforcement: We may
also disclose protected health information, so long as applicable legal
requirements are met, for law enforcement purposes. These law enforcement
purposes include: 1) legal processes and otherwise required by law, (2) limited
information requests for identification and location purposes, (3) pertaining
to victims of a crime, (4) suspicion that death has occurred as a result of
criminal conduct, (5) in the event that a crime occurs on our premises, and (6)
medical emergency and it is likely that
a crime has occurred.
Coroners, Funeral Directors,
and Organ Donation: We may disclose protected health information to a
coroner or medical examiner for identification purposes, determining cause of
death or for the coroner or medical examiner to perform other duties authorized
by law. We may also disclose protected health information to a funeral
director, as authorized by law, in order to permit the funeral director to
carry out their duties. We may disclose such information in reasonable
anticipation of death. Protected health information may be used and disclosed
for cadaver organ, eye or tissue donation purposes.
Research: We may disclose
your protected health information in certain limited cases to researchers when
their research has been determined by
an Institutional Review Board to not adversely affect your privacy rights. An
example of this might be research concerning medical treatment outcomes in
which personally identifying information will not be disclosed by the researcher.
Except in limited cases like this, the general rule is that your protected
health information will not be used for research purposes without your
authorization.
Criminal Activity or Serious
Threat to Health or Safety: 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.
Armed Forces Personnel: We
may use and disclose the protected health information of individuals who are
Armed Forces personnel for activities deemed necessary by appropriate military
command authorities to assure the proper execution of the military mission. This
includes information relating to a member’s fitness for duty or ability to
perform any particular mission or assignment. We will also disclose protected
health information to the Department of Veterans Affairs to assist in
determinations of eligibility for benefits after military service.
Other Special Government
Functions: When the appropriate
conditions apply, we may disclose
protected health information for other special government functions, such as
relating to foreign military members, and national security and
intelligence activities
Workers’ Compensation: Your
protected health information may be disclosed by us as authorized to comply
with workers’ compensation laws and other similar legally established programs.
Patients in Correctional
Facilities: We may use or disclose your protected health information if you
are an inmate of a correctional facility and your physician created or received
your protected health information in the course of providing care to you.
Required Uses and Disclosures:
Under the law, we must make disclosures to you and when required by the
Secretary of the Department of Health and Human Services to investigate or
determine our compliance with the requirements of Section 164.500 et. seq.
E. Other Privacy Practices Concerning Uses and Disclosures.
We will share your protected
health information with third party "business associates" that
perform various activities for our office.This includes insurance contractors,
contractors that operate our computer information systems, and other third
parties that support the administration and management of our office. 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 or agreement 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 appointment
reminders and 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
services we offer. We may also send you information about products or services
that we believe may be beneficial to you.
2.
Your Rights.
Following is a statement of your
rights with respect to your protected health information and a brief
description of how you may exercise these rights.
You have the right to inspect
and copy your protected health information. In general, you may inspect and obtain a copy of
protected health information about you. Under federal law, however, you may not
inspect or copy the following records; psychotherapy notes, information
compiled in reasonable anticipation of, or use in, a civil, criminal, or
administrative action or proceeding, and protected health information that is
subject to law that prohibits access to protected health information. There are
also certain other exceptions. Please note that you may be charged a fee to
cover the costs of providing you the information. Depending on the
circumstances, a decision to deny access may be reviewed. Please contact our
office if you have questions about access to your health record.
You have the right to request a
restriction of your protected health information. This means you may ask us
not to use or disclose any part of your protected health information for the
purposes of treatment, payment or healthcare operations. You may also request
that any part of your protected health information not be disclosed to family
members or friends who may be involved in your care or for notification
purposes as described in this Notice of Privacy Practices. Your request must
state the specific restriction requested, to whom you want the restriction to
apply and an expiration date.
Our office is not required to agree to a restriction
that you may request. In general, if our
office does agree to the requested restriction, we may not use or disclose your
protected health information in violation of that restriction. If you wish to request a restriction, you
need to make your request to the person or level of management that would be
involved in applying the restriction. For example, if your request is that your
physicians or dentists not disclose certain information to a family member,
that request would be made to your physician or dentist. You may request a
restriction in writing via a letter or electronic message. You will receive a
response to your request.
You have the right to request
to receive confidential communications from us by alternative means or at an
alternative location. We will accommodate reasonable requests. We may also
condition this accommodation by asking you for information as to how payment
will be handled (if applicable) or specification of an alternative address or
other method of contact. We will not request an explanation from you as to the
basis for the request. Please make this request in writing or by electronic
message to our office manager.
You may have the right to have our
office amend your protected health information. This means you may request
an amendment of protected health information about you if it is inaccurate or
incomplete. Any such request must be in writing and provide a reason to support
the requested amendment. In certain
cases, we may deny your request for an amendment. If we deny your request for
amendment, you have the right to file a statement of disagreement with us and
we may prepare a rebuttal. Please contact Dr. Raymond M. Klein if you have
questions about amending your protected health information.
You have the right to receive
an accounting of certain disclosures we have made, if any, of your protected
health information. This right applies to disclosures for purposes other
than treatment, payment or healthcare operations as described in this Notice of
Privacy Practices. It excludes disclosures we may have made to you, to family
members or friends involved in your care, or for notification purposes. You
have the right to receive specific information regarding these disclosures that
occurred after April 14, 2003. You may request a shorter timeframe. This right
to receive this information is subject to certain other exceptions,
restrictions and limitations.
You have the right to obtain a
paper copy of this notice from our office or view it electronically at www.dr4gums.com.
You have the right to file a
complaint with our office or the Department of Health and Human Services if
you believe your privacy rights have been violated. You may file a complaint in
writing with Dr. Raymond M. Klein. No
retaliation will occur against you for filing a complaint
This notice is effective in its entirety as
of April 14, 2003.