This notice describes how medical/dental information about a patient may be used and disclosed. Please read carefully.
Protected Health Information (PHI) is information that may identify you and that relates to your past, present, or future physical or mental health or condition and related health-care services. This notice of privacy practices describes a patient's rights and how the office of Jason T. Rothenberg, DMD, MS may use and disclose PHI to carry out treatment, payment (insurance submission), health care operations, and for other purposes permitted or required by law.
Jason T. Rothenberg, DMD, MS will not use or disclose PHI about a patient without your or a legal guardian's written permission, except as described in this notice. We are required by law to maintain the privacy of PHI and to provide individuals with notice of our legal duties and privacy practices with respect to PHI. We are also required to abide by the terms of this notice of privacy practices. We may change our practices and this notice and make the new notice effective for the PHI we maintain. If you request it, we will provide you with a revised notice.
Your Rights:
You may obtain a paper copy of our Notice of Privacy Practices upon request at any time.
You may inspect and obtain a copy of your PHI, which usually includes patient information, course of treatment, x-rays, and billing information. We may charge you for copying and mailing, and any supplies needed to fulfill your request. We may deny your request in certain instances, and you may ask to have you denial reviewed.
You may request a change to your PHI. If you review you PHI and find information incomplete or incorrect, you may request an amendment to it for as long as we maintain your PHI. You may request a restriction of your PHI. This means that you may ask us not to disclose or use any part of your PHI for purposes of treatment, payment, or healthcare operations. You may also request that you PHI not be disclosed to certain family members, legal guardians, or friends who may be involved in your care. You must list the individuals to whom you want the restrictions to apply. We are not required to agree to a requested restriction.
How we May Use and Disclose PHI:
For treatment purposes including, but not limited to: treatment planning; healthcare operations; health-related communications to individuals involved in your care or payment for your care.
For payment and insurance information.
For public safety related operations including, but not limited to: the FDA; worker's compensation; public health or disease control; law enforcement officials; coroners, medical examiners, and funeral directors; correctional facilities; military authorities; issues of National security; or victims of abuse, neglect, or domestic violence.
Please notify the office of Jason T. Rothenberg, DMD, MS if you have any questions related to this notice.
I have received a copy of this notice.