JOHN P. BLAZIC, DDS, INC.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS
IMPORTANT TO US.
OUR LEGAL DUTY
We are required by applicable federal and state law to
maintain the privacy of your health information. We are also required to
give you this Notice about our privacy practices, our legal duties, and
your rights concerning your health information. We must follow the
privacy practices that are described in this Notice while it is in
effect. This Notice takes effect April 14, 2003, and will remain in
effect until we replace it.
the right to change our privacy practices and the terms of this Notice at
any time, provided such changes are permitted by applicable law. We
reserve the right to make the changes in our privacy practices and the new
terms of our Notice effective for all health information that we maintain,
including health information we created or received before we made the
changes. Before we make a significant change in our privacy practices, we
will change this Notice and make the new Notice available upon request.
request a copy of our Notice at any time. For more information about our
privacy practices, or for additional copies of this Notice, please contact
us using the information listed at the end of this Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for
treatment, payment, and healthcare operations. For example:
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
this information with such specialist and obtain input.
We submit a request for payment to your health/dental insurance company.
The health/dental insurance company requests information from us regarding
medical/dental care given. We may use and disclose your health information
to obtain payment for services we provide to you.
We may use and disclose your health information in connection with our
healthcare operations. Healthcare operations include quality assessment
and improvement activities, reviewing the competence or qualifications of
healthcare professionals, evaluating practitioner and provider
performance, conducting training programs, accreditation, certification,
licensing or credentialing activities.
In addition to our use of your health information for
treatment, payment or healthcare operations, you may give us written
authorization to use your health information or to disclose it to anyone
for any purpose. If you give us an authorization, you may revoke it in
writing at any time. Your revocation will not affect any use or
disclosures permitted by your authorization while it was in effect.
Unless you give us a written authorization, we cannot use or disclose your
health information for any reason except those described in this Notice.
Persons Involved In Care:
We may use or disclose
health information to notify, or assist in the notification of (including
identifying or locating) a family member, your personal representative or
another person responsible for your care, of your location, your general
condition, or death. If you are present, then prior to use or disclosure
of your health information, we will provide you with an opportunity to
object to such uses or disclosures. In the event of your incapacity or
emergency circumstances, we will disclose health information based on a
determination using our professional judgment disclosing only health
information that is directly relevant to the personís involvement in your
healthcare. We will also use our professional judgment and our experience
with common practice to make reasonable inferences of your best interest
in allowing a person to pick up filled prescriptions, medical supplies,
x-rays, or other similar forms of health information.
We may use or disclose your health information to provide you with
appointment reminders (such as voicemail messages, postcards, or letters).
record we maintain and billing records are the physical property of this
practice. The information in it, however, belongs to you.
You have the right to look at or get copies of your health information,
with limited exceptions. You may request that we provide copies in a
format other than photocopies. We will use the format you request unless
we cannot practicably do so. (You must make a request in writing to
obtain access to your health information. You may obtain a form to
request access by using the contact information listed at the end of this
Notice. We will charge you a reasonable cost-based fee for expenses such
as copies and staff time. You may also request access by sending us a
letter to the address at the end of this Notice. If you request copies,
we will charge you $1.00 per page for pages 1-10; 50 cents for pages
11-50; and 25 cents for pages 51 and higher plus actual cost of postage if
you want the copies mailed to you. If you request an alternative format,
we will charge a cost-based fee for providing your health information in
that format. If you prefer, we will prepare a summary or an explanation
of your health information for a fee. Contact us using the information
listed at the end of this Notice for a full explanation of our fee
You have the right to
receive a list of instances in which we or our business associates
disclosed your health information for purposes, other than treatment,
payment, healthcare operations and certain other activities, for the last
6 years, but not before April 14, 2003. If you request this accounting
more than once in a 12-month period, we may charge you a reasonable,
cost-based fee for responding to these additional requests.
dental office may disclose a patientís PHI to that patient on request.
dental office may disclose to a patientís personal representative PHI
relevant to the representative capacity. We will not disclose to a
personal representative we reasonably believe may be abusive to a
patient any PHI we reasonably believe may promote or further such abuse.
dental office will not use or disclose a patientís PHI for fundraising
purposes without the patientís Authorization.
dental office will not use or disclose PHI for marketing without a
patientís Authorization unless the marketing is in the form of a
promotional gift of nominal value that we provide, or face-to-face
communications between us and the patient.
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 about your general condition, or your death.
our best judgment, we may disclose to a family member, other relative,
close personal friend, or any other person you identify, health
information relevant to that personís involvement in your care or in
payment for such care if you do not object or in an emergency.
dental office may use or disclose PHI in the following types of
situations, provided procedures specified in the Privacy Rules are
For public health
To health oversight
To coroners, medical
examiners, and funeral directors;
To employers regarding
work-related illness or injury;
To the military;
To federal officials for
lawful intelligence, counterintelligence, and national security
To correctional institutions
In response to subpoenas and
other lawful judicial processes;
To law enforcement
To report abuse, neglect, or
As required by law;
As part of research
As authorized by state
workerís compensation laws.
and disclosures besides those identified in this Notice will be made only
as otherwise authorized by law or with your written authorization and you
may revoke the authorization as previously provided.
You have the right to
request that we place additional restrictions on our use or disclosure of
your health information. We are not required to agree to these additional
restrictions, but if we do, we will abide by our agreement (except in an
You have the right to request that we communicate with you
about your health information by alternative means or to alternative
locations. (You must make your request in writing.) Your request
must specify the alternative means or location, and provide satisfactory
explanation how payments will be handled under the alternative means or
location you request.
You have the right to
request that we amend your health information. (Your request must be in
writing, and it must explain why the information should be amended.) We
may deny your request under certain circumstances.
If you receive this Notice on our Web site or by electronic mail (e-mail),
you are entitled to receive this Notice in written form.
The practice is required to:
the privacy of your health information as required by law.
you with a notice of our duties and privacy practices as to the
information we collect and maintain about you.
the terms of this Notice.
you if we cannot accommodate a requested restriction or request.
Accommodate your reasonable requests 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
QUESTIONS AND COMPLAINTS
If you want more information about our
privacy practices or have questions or concerns, please contact us.
If you are concerned that we may have
violated your privacy rights, or you disagree with a decision we made
about access to your health information or in response to a request you
made to amend or restrict the use or disclosure of your health information
or to have us communicate with you by alternative means or at alternative
locations, you may complain to us using the contact information listed at
the end of this Notice. You also may submit a written complaint to the
U.S. Department of Health and Human Services. We will provide you with
the address to file your complaint with the U.S. Department of Health and
Human Services upon request.
We support your right to the privacy of
your health information. We will not retaliate in any way if you choose
to file a complaint with us or with the U.S. Department of Health and
Contact Officer: Coralee Seifert, Office
Address: 1251 Nilles Road Suite 12
Fairfield OH 45014-7205