Notice of Privacy Practices for Protected
Health Information
Revised Date: 3-06-2019
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! |
Who is covered
by this notice:
This
notice describes practices in the services provided for Orofacial-Myofunctional
Therapy.
My Pledge
Regarding Medical Information:
I
understand that your health information is personal. I am committed to protecting this information. I create a record of care and services
you/your child receives. I need this
record to provide you with quality care and to comply with certain legal
requirements.
This
notice will tell you about the ways in which I may use and disclose your health
information. I also describe your rights
and certain obligations I have regarding the use and disclosure of health
information.
I
am required by law to:
·
Make sure your health information is
kept private
·
Give you this notice of my legal duties
and privacy practices
·
Follow the terms of the notice that is
currently in effect
How I may
use and disclose your health information:
The
following categories describe different ways I use and disclose medical
information. I will explain what I mean
and give some examples for each category.
Not every use or disclosure in a category will be listed. However, all of the ways I am permitted to
use and disclose information will fall within one of the categories.
Uses of
medical information that require authorization:
Disclosure
of medical information not related to treatment, payment, or healthcare
operations or not otherwise covered by this notice (e.g., under “Special
Situations”) can be made only with your specific written authorization. You may revoke that authorization in writing
any time. If you revoke your permission,
I will no longer use or disclose medical information about you for the reasons
covered by your written authorization.
However, I will not be able to take back any disclosures I have already made with your prior
permission.
Your
Rights regarding medical information about you:
You
have the following rights regarding medical information I maintain about you:
·
Right to review
and copy: You have the right to inspect and obtain a copy of
medical information that may be used to make decisions about your care. Usually, this information includes medical
and billing records, but does not include information compiled for use in or
created in anticipation of a civil, criminal or administration action or
proceeding.
·
You must submit your request for your
medical information in writing to the Privacy Officer. If you request a copy of the information, I
will charge a fee of $35.00 for the costs of copying mailing or other supplies associated
with your request.
·
Right to amend: If you
feel medial information I have about you is incorrect or incomplete, you may
ask me to amend the information. You
have the right to request an amendment for as long as the information is
maintained.
·
Submit your request to the Privacy Officer
in writing and include a reason that supports your request.
·
We may deny your request if you ask us to
amend information that was provided to us by another provider or for
information I believe is accurate and complete.
·
I am not required to agree to your
request. Furthermore, I will not comply
with any request, asking me to withhold information from insurance companies
that are billed for services.
·
You must make your request for any
restrictions in writing to the Privacy Officer.
In your request, you must tell me the following information:
o
What information you want to limit
o
Whether you want to limit my use, disclosure
or both
o
To whom you want the limits to apply (for
example, to the person driving your child to therapy appointments)
·
You muse make your request for
confidential communications in writing to the Privacy Officer. I will not ask you the reason for your
request. I will accommodate all
reasonable requests. Your request must
specify how or where you wish to be contacted.
If we maintain a website, providing
information about our entity, this Notice will be on the website.