THIS NOTICE DESCRIBES HOW MEDICAL/DENTAL 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. Tarsitano
OUR OBLIGATIONS:
We are required by law to:
• Maintain the privacy of health information about you;
• Give you this notice of our legal duties and privacy practices regarding health information about you;
• Follow the terms of our notice that are currently in effect.
HOW WE MAY USE AND DISCLOSE YOUR HEALTH INFORMATION:
The following describes the ways we may use and disclose health information that identifies you. Except for the purposes described below, we will use and disclose Health Information only with your written permission. You may revoke such permission at any time by writing to Dr. Tarsitano.
For Treatment. We may use and disclose Health Information for your treatment and to provide you with treatment‑related health care services. For example, we may disclose Health Information to doctors, nurses, technicians, or other personnel, including people outside our office, who are or who may become involved in your medical/dental care and may need the information in connection with such care.
For Payment. We may use and disclose Health Information so that we or others may bill and receive payment from you, an insurance company or a third party for the treatment and services you received. For example, we may give your health plan information about you so that they will pay for your treatment.
For Health Care Operations. We may use and disclose Health Information for health care operations purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and to operate and manage our office. For example, we may use and disclose Health Information for the purpose of evaluating the way we communicate with patients. We also may share Health Information with other entities that have a relationship with you (for example, your health plan) for their health care operation activities.
Appointment Reminders, Treatment Alternatives and Health‑Related Benefits and Services. We may use and disclose Health Information to contact you to remind you that you have an appointment with us. We also may use and disclose Health Information to tell you about treatment alternatives or health‑related benefits and services that may be of interest to you.
Individuals Involved in Your Care or Payment for Your Care. When appropriate, we may share Health Information with a person who is involved in your medical/dental care or payment for your care, such as your family or a close friend. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.
SPECIAL SITUATIONS:
As Required by Law. We will disclose Health Information when required to do so by international, federal, state or local law.
To Avert a Serious Threat to Health or Safety. We may use and disclose Health Information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may be able to help prevent the threat.
Organ and Tissue Donation. If you are an organ donor, we may use or release Health Information to organizations that handle organ procurement or other entities engaged in procurement, banking or transportation of organs, eyes or tissues to facilitate organ, eye or tissue donation and transplantation.
Military and Veterans. If you are a member of the armed forces, we may release Health Information as required by military command authorities. We also may release Health Information to the appropriate foreign military authority if you are a member of a foreign military.
Workers' Compensation. We may release Health Information for workers' compensation or similar programs. These programs provide benefits for work‑related injuries or illness.
Public Health Risks. We may disclose Health Information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and report to the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
Health Oversight Activities. We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.
Lawsuits and Disputes. If there is a pending judicial or administrative proceeding, we may disclose Health Information in response to a court or administrative order. We also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Law Enforcement. We may release Health Information if asked by a law enforcement official for the following reasons:
(1) in response to a court order, subpoena, warrant, summons or similar process;
(2) limited information to identify or locate a suspect, fugitive, material witness or missing person;
(3) about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person's agreement;
(4) about a death we believe may be the result of criminal conduct;
(5) about criminal conduct on our premises; and
(6) in an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.
Coroners and Medical Examiners. We may release Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death.
National Security and Intelligence Activities. We may release Health Information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Protective Services for the President and Others. We may disclose Health Information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or to conduct special investigations.
Inmates or Individuals in Custody. If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Health Information to the correctional institution or law enforcement official. This release would be if necessary:
(1) for the institution to provide you with health care;
(2) to protect your health and safety or the health and safety of others; or
(3) for the safety and security of the correctional institution.
YOUR RIGHTS: You have the following rights regarding Health Information we have about you:
Right to Inspect and Copy. You have a right to inspect and copy Health Information that may be used to make decisions about your care or payment for your care. This includes medical/dental and billing records. In certain circumstances, we have the right to deny your request to inspect and copy. To inspect and copy this Health Information, you must make your request, in writing, to Dr. Tarsitano.
Right to Amend. If you feel that Health Information we have is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our office. In certain circumstances, we have the right to deny your request to amend. To request an amendment, you must make your request, in writing, to Dr. Tarsitano.
Right to an Accounting of Disclosures. You have the right to request a list of certain disclosures we made of Health Information for purposes other than treatment, payment and health care operations or for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to Dr. Tarsitano.
Right to Request Restrictions. You have the right to request a restriction or limitation on the Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Health Information we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make your request, in writing, to . We are not required to agree to your request. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.
Right to Request Confidential Communications. You have the right to request that we communicate with you about medical/dental matters in a certain way or at a certain location. For example, you may ask that we only contact you by mail or at work. To request confidential communications, you must make your request, in writing, to Dr. Tarsitano. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests, but we will not accommodate any request that we believe may impede the care we provide to you.
Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice at our web site, www.drtarsitano.com. To obtain a paper copy of this notice, please contact Dr. Tarsitano.
CHANGES TO THIS NOTICE:
We reserve the right to change this notice and make the new notice apply to Health Information we already have as well as any information we receive in the future. We will post a copy of our current notice at our office. This section will contain the effective date, which is 1 March 2003.
COMPLAINTS:
If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact Dr. Tarsitano. All complaints must be made in writing. You will not be penalized for filing a complaint.
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