Notice of Privacy Practices for Protected Health Information
This notice describes how medical information about you may be used and disclosed, and how you can get access to this information. PLEASE REVIEW CAREFULLY!
With your consent, the practice is permitted by federal privacy laws to make uses and disclosures of your health information for purposed of treatment, payment, and health care operations. Protected Health Information (PHI) is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination, test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.
Examples 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 those services.
Your Health Information Rights
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:
- 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 will try to reasonably comply with any request;
- 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 will try to reasonably comply with any request;
- Request that you be allowed to inspect and copy your health record and billing record- you may exercise this right by delivering the request in writing to our office;
- Appeal a denial of access to your Protected Health Information except in certain circumstances.
- Request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office;
- 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 if your protected health information;
- 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;
- Request that communication of your health information be made by alternate means or at alternative location by delivering the request in writing to our office; and.
- 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 the Practice Manager at 504 W 42nd St. Kearney, NE 68845. 308-455-1944, in person or in writing, during normal business hours. They will provide you with assistance on the steps to take to exercise your rights.
Our Responsibilities:
The practice is required to:
- Maintain the privacy of your health information as required by law;
- Provide you with a notice of our duties and privacy practice as to the information we collect and maintain about you;
- Abide by the terms of this Notice;
- Notify you if we cannot accommodate a requested restrictions or request; and
- Accommodate your reasonable request 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.
To Request Information or File a Complaint
If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact our Practice Manager at 504 W 42nd St. Kearney, NE 68845. 308-455-1944.
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 our Practice Manager. You may also file a complaint with the US Department of Health and Human Services (HHS) at (http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html).
- 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.
- We cannot, and will not, retaliate against you for filing a complaint with the Secretary.
Other Disclosures and Uses
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 your general condition, or for payment in case of 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.
Abuse & Neglect
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 of 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 may revoke the authorization as previously provided.
Website
If we maintain a website that provides information about out entity, this Notice will be on the website.
Effective Date: 5/24/2022
Address: 504 W 42nd Street, Kearney, Nebraska 68845
Phone: 308-455-1944
Fax: 308-455-1920
Compliance Officer: Caitlin Pelster catilin@sandhillsoralfacialsurgery.com
Office Manager: Nicole Tilley nicky@sandhillsoralfacialsurgery.com