Effective date of Notice: September 1, 2017
NOTICE OF PRIVACY PRACTICES FOR ALL DENTAL PRACTICES AFFILIATED WITH OR CONTRACTING WITH CANDID CARE CO. WITH RESPECT TO THE PROVISION OF CLEAR ALIGNER THERAPY
c/o Candid Care Co., 41 Union Square W, 2nd Floor, New York, NY 10003 1-844-295-6915 firstname.lastname@example.org Attn: Sam Levine
THIS NOTICE DESCRIBES HOW PERSONAL AND HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. This Notice describes how we protect your health information and what rights you have regarding your health information. If you have any questions about this Notice, please contact the contact person shown above.
USES AND DISCLOSURES WITHOUT YOUR PERMISSION
We may disclose your health information for certain purposes without your authorization, including the following:
Treatment, Payment and Health Care Operations. The most common reason why we use or disclose your health information is for treatment, payment or health care operations.
Treatment: We may use or disclose your information to treat you. For example, we may use or disclose your information to order the development of a draft treatment plan or to communicate with a dental laboratory regarding dental appliances being developed or modified for you; schedule an appointment for you; perform a dental or physical examination; perform diagnostic tests; prescribe medications and fax or send them electronically to be filled; refer you to another health care provider for additional or specialist services; or get copies of your health information from another health care provider that you may have seen before.
Payment: We may use or disclose your information to obtain payment for the services we provide to you. For example, we may use or disclose your information to ask you or your insurance company about your dental insurance coverage or other sources of payment; to prepare and send bills or claims; or to collect unpaid amounts (either ourselves or through a collection agency or attorney).
Health Care Operations: We may use or disclose your information for certain administrative and managerial activities that are necessary for us to run our business. For example, we may use or disclose your information to train or evaluate our staff; to conduct financial or billing audits; to conduct internal quality assurance; to participate in managed care plans; to defend legal matters; to conduct business planning; or to contract for storage of our records.
Disclosures Unless You Object. Unless you instruct us not to, we may release health information about you to a friend, family member or other person who is involved in your medical and dental care.
Other Uses and Disclosures
In some limited situations and if certain conditions are satisfied, we may also use or disclose your information without your permission. Not all of these situations will apply to us; some may never occur at all. Such uses or disclosures are:
when a state or federal law mandates that certain health information be reported for a specific purpose;
for public health purposes, such as contagious disease reporting, investigation or surveillance, and notices to and from the federal Food and Drug Administration regarding drugs or medical devices;
to governmental authorities about victims of suspected abuse, neglect or domestic violence;
for health oversight activities, such as for the licensing of dentists, for audits by Medicare or Medicaid, or for investigation of possible violations of health care laws;
for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime, to report or provide information about a crime;
to a medical examiner to identify a dead person or to determine the cause of death, or to funeral directors to aid in burial, or to organizations that handle organ or tissue donations;
for health related research that has been approved by an Institutional Review Board or its equivalent;
to prevent a serious threat to health or safety;
for specialized government functions, such as for the protection of the president or high ranking government officials, for lawful national intelligence activities, for military purposes, or for the evaluation and health of members of the foreign service;
disclosures of de-identified information;
disclosures relating to worker’s compensation programs;
disclosures of a “limited data set” for research, public health, or health care operations;
incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
disclosures to “business associates” who perform health care operations for us and who agree to comply with privacy and security laws and regulations that apply to them; and
APPOINTMENT REMINDERS AND OTHER MATTERS; MARKETING
We may call (which may include leaving voice mails), write, E-mail or message (including push notifications)(“communicate”) to remind you of scheduled appointments or the need to make a routine appointment, including for dental monitoring. We may also communicate to notify you of other treatments or services available that might help you. In addition, we may communicate to follow up, conduct quality assessment, ask for reviews, feedback, assessment of satisfaction, complaints or similar activities. We will not use your information for marketing purposes without your authorization. You understand that if we contact you to seek authorization for marketing, and if you decline to provide such consent this will not affect your treatment and we will not repeatedly bother you for such authorization.
USES AND DISCLOSURES with your permission
We will not make any other uses or disclosures of your information unless you sign a written “authorization form.” The content of an “authorization form” is determined by federal law. Sometimes, we may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate the process if it is your idea for us to send your information to someone else. Typically, in this situation you will give us a properly completed authorization form or you can use one of ours.
If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign the authorization, you may revoke it at any time unless we have already acted in reliance upon it. Your revocation of authorization must be in writing and sent to the contact person named at the beginning of this Notice.
We will request your authorization before disclosing any information relating to treatment for mental health or substance abuse or HIV or AIDS. Most uses and disclosures of any psychotherapy notes and of your health information for marketing purposes and for the sale of your health information require your written authorization.
YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION
The law gives you many rights regarding your health information. You can request any of the following by sending a written request to the contact person named at the beginning of this Notice:
ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. Except as described in the next sentence, we do not have to agree to do this, but if we agree, we must honor the restrictions that you want. We are required by law to agree to a request to restrict disclosure of your health information to a health plan if the disclosure is for payment or health care operations and pertains to a health care item or service for which you paid in full out of pocket. If you want to ask us for a restriction, send a written request to the contact person at the address, fax or e-mail shown at the beginning of this Notice.
ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home or only on your cell phone, by mailing health information to a different address, or by using e-mail to your personal e-mail address. We will accommodate these requests if they are reasonable and if you pay us for any extra cost. If you want to ask us for this kind of confidential communication, send a written request to the contact person at the address, fax or e-mail shown at the beginning of this Notice.
ask to see or to get photocopies of your health information. Generally, except in a few limited situations, you will be able to review or have a copy of your health information within 30 days of asking us. You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation and instructions about how to get an impartial review of our denial if one is legally available. By law, we can have one 30 day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If we have information about you in electronic form, we will provide it to you electronically if we can agree with you about the format, such as PDF. If you wish, you can request that electronic health information that we have about you be sent to someone else that you specify. We will send the electronic information where you request so long as your instructions are clear and there is no other reason why we need to deny your request. You may have to pay for the cost of producing an electronic copy of your health information. If you want to review or get copies of your health information, send a written request to the contact person at the address, fax or e-mail shown at the beginning of this Notice.
ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information and others that you specify. If we do not agree, you can write a statement of your position and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30 day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request to the contact person at the address, fax or e-mail shown at the beginning of this Notice.
get a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want). By law, the list will not include: disclosures for purposes of treatment, payment or health care operations (unless we have made disclosures from an electronic health record), disclosures that were made with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30 day extension of time if we notify you of the extension in writing. If you want a list, send a written request to the contact person at the address, fax or e-mail shown at the beginning of this Notice.
get additional paper copies of this Notice of Privacy Practices upon request to the contact person at the address, fax or e-mail shown at the beginning of this Notice.
be notified in accordance with law if there is ever a data breach that involves your health information.
OUR NOTICE OF PRIVACY PRACTICES
By law, we must abide by the terms of this Notice of Privacy Practices. We reserve the right to change this Notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to all health information that we maintain as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new Notice in our office, have copies available in our office, and post it on our Web site.
If you think that we have not properly respected the privacy of your health information, you are free to complain to us or to the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the contact person at the address, fax or e-mail shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone.
FOR MORE INFORMATION
If you want more information about our privacy practices, call or visit the contact person at the address or e-mail shown at the beginning of this Notice.
EFFECTIVE DATE This Notice is effective September 1, 2017.