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NOTICE OF PRIVACY
PRACTICES
HEATHERWOOD DENTAL, PLLC
DR. MICHAEL CRIDDLE/DR. MICHAEL MOWER
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. 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 duties, 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: April 15, 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 such changes are permitted
by applicable law. Before we make a significant change in our privacy
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.
We use and disclose health information about you for treatment, payment,
and healthcare operations.
For example:
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We may use and disclose
your health information to a physician or other healthcare provider
providing treatment to you
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We may use and disclose
your health information to obtain payment for services we provide to
you.
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We may use and disclose
your health information in connection with our healthcare operations.
Health care 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.
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 affect any use of 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.
We must disclose your health information to you as described in the
patient rights section 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. 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, or 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 judgment disclosing only
health information that is directly relevant to the persons involvement in
your healthcare. We will also use our professional judgment 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.
We will not use your health information for marketing communications
without your written authorization. We may use or disclose your health
information when we are required to do so by law. 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
health or safety or the health or safety of others. We may disclose to
military authorities the health information for 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 official having
lawful custody of protected health information of inmate or patient under
certain circumstances. We may use or disclose your health information to
provide you with appointment reminders (such as voicemail messages,
postcards, or letters).
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 $10.00 for each page, and $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.
You have the right to receive a list of instances in which we or our
business associates disclosed you 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. 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). 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. You have the right to request
that we amend your health information. (Your request must be in writing
and it must explain why the information should be amended.) We may deny
your request under certain circumstances.
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. 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 make 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 US Department of
Health and Human Services. We will provide you with the address to file
your complaint with the US Department of Health and Human Services upon
request. We support your right to the privacy of your health information.
We will not retaliate in any way if you choose to file a complaint with us
or with the US Department of Health and Human Services.
Contact Officer: Dr. Michael Criddle/Dr. Michael Mower
Heatherwood Dental, PLLC
Address: 13619 North 59th Avenue
Glendale AZ 85304
Telephone: 602-938-2911 Fax: 602-938-5735
This form is educational only, does not constitute legal advice, and
covers only federal, not state law.
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