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 of Privacy Practices, please contact our Privacy Official by calling (650) 756-5630 or by writing Orthosmoke.org, 1800 Sullivan Ave. #307, Daly City, CA 94015.
This Notice of Privacy Practices describes how Orthosmoke.org may use and disclose your protected health information (PHI) 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.
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 Orthosmoke.org maintains at that time. Upon your request, Orthosmoke.org will provide you with any revised Notice of Privacy Practices by calling the practice and requesting that a revised copy be sent to you in the mail or asking for one at the time of your next appointment.
Uses and Disclosures of Protected Health Information Based Upon Your Written Consent
You will be asked by Orthosmoke.org to sign a consent form. Once you have consented to use and disclosure of your protected health information for treatment, payment and health care operations by signing the consent form, Orthosmoke.org will use or disclose your protected health information as described in this Section. Your protected health information may be used and disclosed by Orthosmoke.org, the office staff and others outside of our office that are involved in your care and treatment for the purpose of providing medical care services to you. Your protected health information may also be used and disclosed to pay your medical care bills and to support the operation of Orthosmoke.org practice.
Treatment: We will use and disclose your protected health information to provide, coordinate or manage your medical care and any related services. This includes the coordination or management of your medical care with a third party that has already obtained your permission to have access to your protected health information. In addition, Orthosmoke.org 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 Orthosmoke.org, becomes involved in your care by providing assistance with your medical care diagnosis or treatment to Orthosmoke.org
Payment: Your protected health information will be used, as needed, to obtain payment for your medical care services. This may include certain activities that your health insurance plan may undertake before it approves or pays for the medical care services Orthosmoke.org recommends for you.
Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of Orthosmoke.org's practice. In addition, Orthosmoke.org 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 Orthosmoke.org is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.
We will share your protected health information with third party "business associates" that perform various activities for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, Orthosmoke.org will have a written contract that contains terms that will protect the privacy of your protected health information.
Uses and Disclosures of Protected Health Information Based upon Your Written Authorization
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 Orthosmoke.org or the practice has taken an action in reliance on the use or disclosure indicated in the authorization.
Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to Object
We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then Orthosmoke.org may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your medical care will be disclosed.
Others Involved in Your Healthcare:
Unless you object, Orthosmoke.org 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 medical care. If you are unable to agree or object to such a disclosure, Orthosmoke.org may disclose such information as necessary if he/she determines that it is in your best interest based on his/her 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.
Emergencies: We may use or disclose your protected health information in an emergency treatment situation. If this happens, Orthosmoke.org will try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If Orthosmoke.org is required by law to treat you and he has attempted to obtain your consent but is unable to obtain your consent, he may still use or disclose your protected health information to treat you.
Communication Barriers: We may use and disclose your protected health information if Orthosmoke.org attempts to obtain consent from you but is unable to do so due to substantial communication barriers and he determines, using professional judgment, that you intend to consent to use or disclosure under the circumstances.
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:
The 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 may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.
You may contact our Privacy Official by calling (650) 756-5630 or by writing to Orthosmoke.org, 1800 Sullivan Ave. #307, Daly City, CA 94015 for further information about the complaint process.
This notice was published and becomes effective on April 14, 2003.
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