NOTICE OF PRIVACY PRACTICES

Dr. Thomas A. Conner

9401 Courthouse Road, Suite 306

Chesterfield, VA. 23832

 

PURPOSE:

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.

This notice takes effect on April 1, 2003 and remains in effect until we replace it.

 

1. OUR PLEDGE REGARDING MEDICAL INFORMATION

The privacy of your medical/dental information is important to us.  We understand that your medical/dental information is personal and we are committed to protecting it.  We create a record of the care and services you receive at our organization.  We need this record to provide you with quality care and to comply with certain legal requirements.  This notice will tell you about the ways we may use and share medical/dental information about you.  We also describe your rights and certain duties we have regarding the use and disclosure of medical/dental information.

 

2. OUR LEGAL DUTY

The Law Requires Us to:   

1. Keep your medical/dental information private
2. Give you this notice describing our legal duties, privacy practices, and your rights regarding your medical/dental information.
3. Follow the terms of the notice that is now in effect.

 

We Have the Right to: 

1. Change our privacy practices and the terms of this notice at any time, provided                           that law permits the changes.
2. Make the changes in our privacy practices and the new terms of our notice effective for all            medical/dental information that we keep, including information previously created or received  before the changes

Notice of Change to Privacy Practices:

1. Before we make an important change in our privacy practices, we will change this notice and make a new notice available upon request.

 

3. USE AND DISCLOSURE OF YOUR MEDICAL/DENTAL INFORMATION

The following section describes different ways that we use and disclose medical/dental information.  For each kind of use or disclosure, we will explain what we mean and give an example.  Not every use or disclosure will be listed.  However, we have listed all of the different ways we are permitted to use and disclose medical/dental information.  We will not use or disclose your medical/dental information for any purpose not listed below, without your specific written authorization.  Any specific written authorization you provide may be revoked at any time by writing to us.

 

FOR TREATMENT:

We may use medical/dental information about you to provide you with medical/dental treatment or services.  We may disclose medical/dental information about you to doctors, nurses, technicians, medical students, or other people who are taking care of you.

        Example:  You are in our office for specific dental treatment and need to be referred to an outside specialist, hospital or oral surgeon’s office for further services. You also have diabetes.  A number of health care and support staff need to know about your diabetes during your stay:

• The doctor treating you for the medical/dental services needs to know if you have diabetes because the diabetes may slow the healing process.
• The pharmacy needs to know about possible medicines that you may need as a diabetic.
• The information about your diabetes may help in your diagnostic testing, and x-ray work.

 

We may also share medical/dental information about you to your other health care providers to assist them in treating you. 

 

FOR PAYMENT:

We may use and disclose your medical/dental information for payment purposes.

Example:  You are treated our office or in another office in which we have referred you.

• We may need to give your health insurance plan information about surgery you received at our organizations that your health plan will repay you or us for any surgery that you paid for.
• We may also tell your health plan about a treatment you are going to receive to get approval or to determine if your plan will pay for the treatment.

 

FOR HEALTH CARE OPERATIONS:

We may use and disclose your medical/dental information for our health care operations.  This might include measuring and improving quality, evaluating the performance of employees, conducting training programs, and getting the accreditation, certificates, licenses and credentials we need to serve you.

 

FOR SECURITY BREACHES:

We may use or disclose your PHI when determining whether a security breach has occurred for purposes of the HIPPAA Breach Notification Rules as set forth in 45 CFR §§ 164.400-414, subpart D. we may also use or disclose your PHI in responding to a breach as required under the HIPPAA Breach Notification Rules. For example, if an individual hacks into our computer network, we would investigate the incident to determine the extent of the breach and if the PHI had been accessed, used or disclosed in violation of the HIPPAA Privacy Rule. If a breach for purposes of HIPPAA has occurred, we would notify you of the breach. We may also be required to notify the media and the U.S. Department of Health and Human Services of  the breach, but your PHI will not be disclosed when such entities are notified of the breach.

 

ADDITIONAL USES AND DISCLOSURES:

In addition to using and disclosing your medical/dental information for treatment, payment, and health care operations, we may use and disclose medical/dental information for the following purposes. 

Notification:  Medical/dental information to notify or help notify:

• a family member
• your personal representative
• another person responsible for your care

We will share information about your location, general condition, or death.  If you are present, we will get your permission.  In case of emergency, and if you are not able to give or refuse permission, we will share only the health information that is directly necessary for your health care, according to our professional judgment.  We will also use our professional judgment to make decisions in your best interest about allowing someone to pick up medicine, medical supplies, x-ray or medical information about you.

 

Disaster Relief:

Medical/dental information with a public or private organization or person who can legally assist in disaster relief efforts.

 

Funeral Director, Coroner, Medical Examiner:

To help them carry out their duties, we may share the medical/dental information of a person who has died with a coroner, medical examiner, or an organ procurement organization.

 

Specialized Government Functions: 

Subject to certain requirements, we may disclose or use health information for military personnel and veterans, for national security and intelligence activities, for protective services for the President and others, for medical suitability determinations for the Department of State, for correctional institutions and other law enforcement custodial situations, and for government programs providing public benefits. 

 

Court Orders and Judicial and Administrative Proceedings:

We may disclose medical information in response to a court or administrative order, subpoena, discovery request, or other lawful process, under certain circumstances.  Under limited circumstances, such as a court order, warrant, or grand jury subpoena, we may share your medical information with law enforcement officials.  We may share limited information with a law enforcement official concerning the medical/dental information of a suspect, fugitive, material witness, crime victim or missing person.  We may share the medical/dental information of an inmate or other person in lawful custody with a law enforcement official or correctional institution under certain circumstances. 

 

Abuse or Neglect:  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 health of others.

 

Workers Compensation:

We may disclose health information when authorized and necessary to comply with laws relating to workers compensation or other similar programs.

 

Law Enforcement:

Under certain circumstances, we may disclose health information to law enforcement officials.  These circumstances include reporting required by certain laws (such as the reporting of certain types of wounds), pursuant to certain subpoenas or court orders, reporting limited information concerning identification and location at the request of a law enforcement official, reports regarding suspected victims of crime at the request of a law enforcement official, reporting death, crimes on our premises, and crimes in emergencies.

 

Your Authorization: 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 or 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.

 

To Your Family and Friends: We muse disclose your health information to you, as described in the Patients 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 you healthcare or with payment for your healthcare, but only if you agree that we may do so.

 

Appointment Reminders:  We may use or disclose your health information to provide you with appointment reminders ( such as voicemail messages, telephone calls/messages, postcards or letters).

 

4 .  YOUR INDIVIDUAL RIGHTS

You Have a Right to:   

1. Look at or get copies of your medical/dental information. You may request that we provide copies in a format other than photocopies.  We will use the format you request unless it is not practical for us to do so.  You must make your request in writing.  You may get the form to request access by using the contact information listed at the end of this notice. 

 

(If you request copies, we will charge you according to our current fee structure, which is indicated on the release form.  Contact us using the information listed at the end of this notice for a full explanation of our fee structure.)

 

2. Receive a list of all the times our business associates or we shared your medical/dental information for purposes other than treatment, payment, and health care operations and other specified exceptions.
3. Request that we place additional restrictions on our use or disclosure of your medical/dental information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in the case of an emergency).
4. Request that we communicate with you about your medical/dental information by different means or to different locations. Your request that we communicate your medical/dental information to you by different means must be made in writing to the contact person listed at the end of this notice.
5. Request that we change your medical/dental information. We may deny your request if we did not create the information you want changed or for certain other reasons.  If we deny your request, we will provide you a written explanation.  You may respond with a statement of disagreement that will be added to the information you wanted changed.  If we accept your request to change the information, we will make reasonable efforts to tell others, including people you name, of the change and to include the changes in any future sharing of that information.

 

QUESTIONS AND COMPLAINTS

 

IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT:

 

Thomas A. Conner, DDS

Terrie Conner (Office Manager)

9401 Courthouse Road, Suite 306

Chesterfield, VA. 23832

 

Tel: (804) 768-7600

Fax:(804) 768-0115

 

revised 3/14/2022