Treatment: We will use your health information for treatment. For example, information obtained by the orthodontist or other members of your healthcare
team will be recorded in your record and used to determine the course of treatment that should work best for you. Your orthodontist will document in your
record his or her expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their
observations, so the physician will know how you are responding to treatment. We will also provide your physician, or a subsequent healthcare provider, with
copies of various reports that should assist him or her in treating you.
Payment: We will use your health information for payment. For example, a bill may be sent to you or your health plan. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.
Health Care Operations: We will use your health information for our regular health care operations. For example, we may use information in your health
record to assess the care and outcome in your case and others like it. This information will then be used in a continued effort to improve the quality and
effectiveness of the services we provide.
Business Associates: We may enter into contracts with persons or entities known as business associates that provide services to or perform functions on
our behalf. Examples include our accountants, consultants, and attorneys. We may disclose your health information to our business associates so they can perform the job we have asked them to do, once they have agreed in writing to safeguard your information.
Notification: We may use or disclose information to assist in notifying a family member, personal representative, or another person responsible for your care, of your location, and general condition. If we are unable to reach your family member or personal representative, then we may leave a message for them at the
phone number that they have provided to us, e.g., on an answering machine.
Communication with Family: 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 payment related to your care.
Appointment Reminders / Health Benefits: We may contact you to provide appointment reminders or information about treatment alternatives or other
health benefits that may be of interest to you.
Funeral Directors and Coroners: We may disclose your health information to funeral directors, and to coroners or medical examiners, to carry out their
duties consistent with applicable law.
Organ Procurement Organizations: Consistent with applicable law, we may disclose your 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.
Research: We may disclose your health 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 health information. We may also disclose your health information to people preparing to conduct a research project, so long as the health information is not removed from us. We may also use and disclose your health information to contact you about the possibility of enrolling in a research study.
Fundraising: We may contact you as part of our fundraising efforts; however, you may opt-out of receiving such communications.
Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product,
and product defects, or post marketing surveillance information to enable product recalls, repairs, or replacement.
Workers’ Compensation: We may disclose health information to the extent authorized by and to the extent necessary, to comply with laws relating to
workers’ compensation or other similar programs established by law.
Public Health Activities: As required by law, we may disclose your health information to public health, or legal authorities, charged with preventing or
controlling disease, injury, or disability.
Health Oversight Activities: We may disclose your health information to health oversight agencies for purposes of legally authorized health oversight
activities, such as audits and investigations necessary for oversight of the health care system and government benefit programs.
Correctional Institution: Should you be an inmate of a correctional institution, we may disclose to the institution, or agents thereof, health information
necessary for your health and the health and safety of other individuals.
Judicial and Administrative Proceedings: We may disclose your health information in a judicial or administrative proceeding if the request for the
information is through an order from a court or administrative tribunal. Such information may also be disclosed in response to a subpoena or other lawful
process if certain assurances regarding notice to the individual or a protective order are provided.
Law Enforcement Purposes / Serious Threat to Health or Safety: We may disclose your health information to enforcement officials for law enforcement
purposes under certain circumstances and subject to certain conditions. We may also disclose your health information to prevent or lessen a serious and
imminent threat to a person or the public (when the disclosure is made to someone we believe can prevent or lessen the threat) or to identify or apprehend an
escapee or violent criminal.
Victims of Abuse, Neglect, and Domestic Violence: In certain circumstances, we may disclose your health information to appropriate government
authorities if there are allegations of abuse, neglect, or domestic violence.
Essential Government Functions: We may disclose your health information for certain essential government functions (e.g., military activity and for national
security purposes). The following uses and disclosures will be made only with your authorization: (i) with limited exceptions, uses and disclosures of your health
information for marketing purposes, including subsidized treatment communications; (ii) disclosures that constitute a sale of your health information; and (iii) other
uses and disclosures not described in this notice. You may revoke your authorization at any time in writing, except to the extent that we have taken action in reliance
on the use or disclosure indicated in the authorization.
Although your health record is the physical property of this office, you have the following rights with respect to your health information.
You may request that we not use or disclose your health information for a particular reason related to treatment, payment, our general healthcare operations, and/or to a particular family member, other relatives or close personal friend. We ask that such requests be made in writing on a form provided by us. Although we will consider your request, please be aware that we are under no obligation to accept it or to abide by it, except as provided below.
If you have paid for services out-of-pocket in full, you may request that we not disclose information related solely to those services to your health plan. We ask that such requests be made in writing on a form provided by us. We are required to abide by such a request, except where we are by law to make a disclosure. We are not to inform other providers of such a request, so you should notify any other providers regarding such a request.
You have the right to receive confidential communications from us by alternative means or at an alternative location. Such a request must be made in writing, and submitted to the Privacy Officer. We will attempt to accommodate all reasonable requests.
You may request to inspect and/or obtain copies of health information about you, which will be provided to you in the time frames established by
law. If we maintain your health information electronically in a designated record set, you may obtain an electronic copy of the information. If you
request a copy (paper or electronic), we will charge you a reasonable, cost-based fee.
If you believe that any health information in your record is incorrect, or if you believe that important information is missing, you may request that we
correct the existing information or add the missing information. Such requests must be made in writing, and must provide a reason to support the
amendment. We ask that you use the form provided by us to make such requests. For a request form, please contact the Privacy Officer.
You may request that we provide you with a written accounting of all disclosures made by us during the time period for which you request (not to
exceed six years), as required by law. We ask that such requests be made in writing on a form provided by us. Please note that accounting does
not include all disclosures, e.g., disclosures to carry out treatment, payment, or healthcare operations and disclosures made to you or your
legal representative or pursuant to an authorization. You will not be charged for your first accounting request in any 12-month period. However, for
any requests that you make thereafter, you will be charged a reasonable, cost-based fee.
You have the right to be notified following a breach of your unsecured protected health information.
You have the right to obtain a paper copy of our Notice of Privacy Practices upon request.
You have the right to complain to us and to the Secretary of the U.S. Department of Health and Human Services (HHS) if you believe we have violated your
privacy rights. We will not retaliate against you for filing a complaint.
For more information or to file a complaint with us, contact our Privacy Officer by phone or mail. To file a complaint with the Secretary of HHS, send your
complaint to our Privacy Officer.
If you have any questions or want more information about this Notice of Privacy Practices, please contact our Privacy Officer.
Signature of Patient or Personal Representative
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
Section A: Patient Giving Consent
Section B: To the Patient Please read the following statements carefully.
Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent.We encourage you to read it carefully and completely before signing this Consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting: Campbell Orthodontics
Phone: (910) 251-1100 Fax: (910) 251-9871
Address: 1516 Doctors Circle Wilmington, NC 28401
Right to Revoke: You will have the right to revoke this Consent at any time by giving us a written notice of your revocation submitted to our o ce. Please understand that revocation of this Consent will not a ect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or continue to treating you if you revoke this Consent.