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.
Each time you visit our office, we make a record of your visit in order to manage the care you
receive. We understand that the medical information that is recorded about you and your health
is personal. The confidentiality and privacy of your health information is also protected under
both state and federal law.
This Notice of Privacy Practices describes how this office may use and disclose your
information and the rights that you have regarding your health information.
How We Will
Use or Disclose Your Health Information
Treatment: We will use your health information for treatment. Your 0rthodontist will
document in your record his or her expectations of the member 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.
Payment: We will use your health information for payment. The information on or
accompanying the bill or insurance claim may include information that identifies you, your
diagnosis, procedures, and supplies used.
Health Care Operations: We may share your
information with other health care providers (i.e., your general dentist. oral surgeon, etc.) in
connection with our rendering orthodontic treatment. 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. We may disclose our 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 /Communication
with Family: 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 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 for us. We may disclose to a
family member, other relative, or any other person you identify as responsible for your 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.
Health Care Information Required by Law: We may use and disclose
your health information when required by federal or state law and when required in court or
administrative proceedings.
Insurance Payments:I hereby authorize and direct payment
of dental insurance benefits otherwise payable to me, directly to Parks, Schmit, and Fuller
Orthodontics.
The following uses and disclosures will be made only with your authorization. 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.