JOHN C. BINKLEY, D.M.D.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
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 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 04-14-03 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 on 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.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and dental
operations. For example:
Treatment: We may use or disclose your health information to a physician, dentist or
other healthcare provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for
services rendered to you by us.
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
Your Authorization: In addition to the above, 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 or disclosures permitted by your authorization while it was in effect.
Unless you give us written consent, 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, as
described in the Patent 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.
Persons Involved In Care: We may use or disclose health information to notify, or
assist in the notification of (including identifying or location) 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 based a determination using our professional judgment
disclosing only health information that is directly relevant to the person’s 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 prescriptions, x-rays or other similar forms of health information.
Marketing Health-Related Services: We will not use or disclose 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 reasonable 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 of
the health or 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 official 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).
Access: You have the right to look at or get copies of your health information, with
limited exceptions. You must 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 o f this Notice. We may 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.
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 receive a list of instances in which we or our
business associates disclosed 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
Alternative Communication: You have the right to request that we communicate with
you about your health information. (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
Amendment: 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.
Electronic Notice: If you receive this Notice via electronic mail, you are entitled to
receive this Notice in written form.
QUESTIONS AND COMPAINTS
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 your 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 address your complaint to us by 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 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 U.S. Department of Health
and Human Services.
Contact Officer: Sabrina B. Zappone