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!
With
your consent, Southern Maine Oral & Maxillofacial Surgery is permitted by federal privacy laws to
make uses and disclosures of your health information for purposes of treatment,
payment, and health care operations.
Protected health information is the information we create and obtain in
providing our services to you.
Such information may include documenting your symptoms, examination and
test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for
those services.
Example
of uses of your health information for treatment purposes:
A
nurse obtains treatment information about you and records it in a health
record. During the course of your
treatment, the doctor determines a need to consult with another specialist in
the area. The doctor will share
the information with such specialist and obtain input.
Example
of use of your health information for payment purposes:
We
submit a request for payment to your health insurance company. The health insurance company requests
information from us regarding medical care given. We will provide information to them about you and the care
given.
Example
of Use of Your Information for Health Care Operations:
We
obtain services from our insurers or other business associates such as quality
assessment, quality improvement, outcome evaluation, protocol and clinical
guidelines development, training programs, credentialing, medical review, legal
services, and insurance. We will share information about you with such insurers
or other business associates as necessary to obtain these services.
The
health record we maintain and billing records are the physical property of the
practice. The information in it,
however, belongs to you. You have
a right to:
á
Request a
restriction on certain uses and disclosures of your health information by
delivering the request in writing to our office. We are not required to grant the request but we will comply
with any request granted;
á
Obtain a
paper copy of this Notice of Privacy Practices for Protected Health Information
("Notice") by making a request at our office;
á
Request
that you be allowed to inspect and copy your health record and billing
recordÑyou may exercise this right by delivering the request in writing to our
office;
á
Appeal a denial
of access to your protected health information except in certain circumstances;
á
Request
that your health care record be amended to correct incomplete or incorrect
information by delivering a written request to our office;
á
File a
statement of disagreement if your amendment is denied, and require that the
request for amendment and any denial be attached in all future disclosures of
your protected health information;
á
Obtain an
accounting of disclosures of your health information as required to be maintained
by law by delivering a written request to our office. An accounting will not include internal uses of
information for treatment, payment, or operations, disclosures made to you or
made at your request, or disclosures made to family members or friends in the
course of providing care;
á
Request
that communication of your health information be made by alternative means or
at an alternative location by delivering the request in writing to our office;
and,
á
Revoke
authorizations that you made previously to use or disclose information except
to the extent information or action has already been taken by delivering a
written revocation to our office.
If
you want to exercise any of the above rights, please contact Ms Kitty Root,
(282-0700, 20 West Cole Rd. Biddeford, ME
04005), in
person or in writing, during normal hours. She will provide you with assistance on the steps to take to
exercise your rights.
The
practice is required to:
á
Maintain
the privacy of your health information as required by law;
á
Provide you
with a notice of our duties and privacy practices as to the information we
collect and maintain about you;
á
Abide by
the terms of this Notice;
á
Notify you
if we cannot accommodate a requested restriction or request; and
á
Accommodate
your reasonable requests regarding methods to communicate health information
with you.
We
reserve the right to amend, change, or eliminate provisions in our privacy
practices and access practices and to enact new provisions regarding the
protected health information we maintain.
If our information practices change, we will amend our Notice. You are entitled to receive a revised
copy of the Notice by calling and requesting a copy of our "Notice"
or by visiting our office and picking up a copy.
If
you have questions, would like additional information, or want to report a
problem regarding the handling of your information, you may contact Ms. Kitty
Root, Office Manager in the Biddeford Office at 282-0700.
Additionally,
if you believe your privacy rights have been violated, you may file a written
complaint at our office by delivering the written complaint to Dr Richard
Crawford. You may also file a
complaint by mailing it to the Secretary of Health and Human Services Regional
Office whose street address is:
John
F. Kennedy Federal Building
Government
Center
Boston,
MA 02203
617/565-1500
á
We cannot,
and will not, require you to waive the right to file a complaint with the
Secretary of Health and Human Services (HHS) as a condition of receiving
treatment from the practice.
á
We cannot,
and will not, retaliate against you for filing a complaint with the
Secretary.
Notification
Unless you object, we may use or disclose your
protected health information to notify, or assist in notifying, a family
member, personal representative, or other person responsible for your care,
about your location, and about your general condition, or your death.
Communication with Family
Using our best judgment, we may disclose to a
family member, other relative, close personal friend, or any other person you
identify, health information relevant to that person's involvement in your care
or in payment for such care if you do not object or in an emergency.
Food and Drug Administration (FDA)
We may disclose to the FDA your protected health
information relating to adverse events with respect to products and product
defects, or post-marketing surveillance information to enable product recalls,
repairs, or replacements.
Workers Compensation
If you are seeking compensation through Workers
Compensation, we may disclose your protected health information to the extent
necessary to comply with laws relating to Workers Compensation.
Public Health
As required by law, we may disclose your
protected health information to public health or legal authorities charged with
preventing or controlling disease, injury, or disability.
We may disclose your protected health
information to public authorities as allowed by law to report abuse or neglect.
Correctional Institutions
If you are an inmate of a correctional
institution, we may disclose to the institution, or its agents, your protected
health information necessary for your health and the health and safety of other
individuals.
Law Enforcement
We may disclose your protected health
information for law enforcement purposes as required by law, such as when
required by a court order, or in cases involving felony prosecutions, or to the
extent an individual is in the custody of law enforcement.
Health Oversight
Federal law allows us to release your protected
health information to appropriate health oversight agencies or for health
oversight activities.
Judicial/Administrative Proceedings
We may disclose your protected health
information in the course of any judicial or administrative proceeding as
allowed or required by law, with your consent, or as directed by a proper court
order.
Other Uses
Other uses and disclosures besides those
identified in this Notice will be made only as otherwise authorized by law or
with your written authorization and you may revoke the authorization as
previously provided.
If we maintain a website that provides
information about our entity, this Notice will be on the website.
Research
á We may disclose information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.
Disaster Relief
á We may use and disclose your protected health information to assist in disaster relief efforts.
Funeral Directors/Coroners
á We may disclose your protected health information to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.
Organ Procurement
Organizations
á Consistent with applicable law, we may disclose your protected health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.
á We may disclose your protected health information for specialized government functions as authorized by law, such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.
Effective Date: April 1st, 2003