R. VANDERMEER D.D.S., P.C.
Notice of Privacy Practices
NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT
are required by law to maintain the privacy of protected health information, to
provide individuals with notice of our legal duties and privacy practices with
respect to protected health information, and to notify affected individuals
following a breach of unsecured protected health information. We must follow
the privacy practices that are described in this Notice while it is in effect.
This amended Notice takes effect 01/01/2013, and will remain in effect until we
reserve the right to change our privacy practices and the terms of this Notice
at any time, provided such changes are permitted by applicable law, and to make
new Notice provisions effective for all protected health information that we
maintain. When we make a significant change in our privacy practices, we will
change this Notice and post the new Notice clearly and prominently at our practice location, and we will provide copies of the new Notice upon request.
may 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.
WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
may use and disclose your health information for different purposes, including
treatment, payment, and health care operations. For each of these categories,
we have provided a description and an example. Some information, such as
HIV-related information, genetic information, alcohol and/or substance abuse
records, and mental health records may be entitled to special confidentiality
protections under applicable state or federal law. We will abide by these
special protections as they pertain to applicable cases involving these types
Treatment. We may use and disclose your health
information for your treatment. For example, we may disclose your health
information to a specialist providing treatment to you.
Payment. We may use and disclose your health
information to obtain reimbursement for the treatment and services you receive
from us or another entity involved with your care. Payment activities include
billing, collections, claims management, and determinations of eligibility and
coverage to obtain payment from you, an insurance company, or another third
party. For example, we may send claims to your dental health plan containing certain health information.
Healthcare Operations. We may use and disclose your
health information in connection with our healthcare operations. For example,
healthcare operations include quality assessment and improvement activities,
conducting training programs, and licensing activities.
Reminders. We may use
or disclose your health information to provide you with appointment reminders
(such as voice mail messages, postcards, or letters).
Individuals Involved in Your Care or Payment for Your
Care. We may disclose your health information to your
family or friends or any other individual identified by you when they are
involved in your care or in the payment for your care. Additionally, we may
disclose information about you to a patient representative. If a person has the
authority by law to make health care decisions for you, we will treat that
patient representative the same way we would treat you with respect to your
may use or disclose your health information to assist in disaster relief
Required by Law. We may use or disclose your health
information when we are required to do so by law.
Public Health Activities. We may disclose your health information for public health activities,
including disclosures to:
o Prevent or control disease, injury or
o Report child abuse or neglect;
o Report reactions to medications or
problems with products or devices;
o Notify a person of a recall, repair,
or replacement of products or devices;
o Notify a person who may have been
exposed to a disease or condition; or
o Notify the appropriate government
authority if we believe a patient has been the
victim of abuse, neglect, or domestic violence.
National Security. We may disclose to military
authorities the health information of Armed Forces personnel under certain
circumstances. We may disclose to authorized federal officials health
information required for lawful intelligence, counterintelligence, and other
national security activities. We may disclose to correctional institution or
law enforcement official having lawful custody the protected health information
of an inmate or patient.
will disclose your health information to the Secretary of the U.S. Department
of Health and Human Services when required to investigate or determine
compliance with HIPAA.
Worker’s Compensation. We
may disclose your PHI to the extent authorized by and to the extent necessary
to comply with laws relating to worker’s compensation or other similar programs
established by law.
Law Enforcement. We may
disclose your PHI for law enforcement purposes as permitted by HIPAA, as
required by law, or in response to a subpoena or court order.
Health Oversight Activities. We may disclose your PHI to an oversight agency for activities authorized
by law. These oversight activities include audits, investigations, inspections,
and credentialing, as necessary for licensure and for the government to monitor
the health care system, government programs, and compliance with civil rights
Judicial and Administrative Proceedings. If you are involved in a lawsuit or a dispute, we may disclose your PHI
in response to a court or administrative order. We may also disclose health
information about you in response to a subpoena, discovery request, or other
lawful process instituted by someone else involved in the dispute, but only if
efforts have been made, either by the requesting party or us, to tell you about
the request or to obtain an order protecting the information requested.
Research. We may
disclose your PHI to researchers when their research has been approved by an
institutional review board or privacy board that has reviewed the research
proposal and established protocols to ensure the privacy of your information.
Coroners, Medical Examiners, and Funeral Directors. We may release your PHI to a coroner or medical examiner. This may be
necessary, for example, to identify a deceased person or determine the cause of
death. We may also disclose PHI to funeral directors consistent with applicable
law to enable them to carry out their duties.
and Disclosures of PHI
Your authorization is required, with
a few exceptions, for disclosure of psychotherapy notes, use or disclosure of
PHI for marketing, and for the sale of PHI. We will also obtain your written
authorization before using or disclosing your PHI for purposes other than those
provided for in this Notice (or as otherwise permitted or required by law). You
may revoke an authorization in writing at any time. Upon receipt of the written
revocation, we will stop using or disclosing your PHI, except to the extent
that we have already taken action in reliance on the authorization.
Access. You have the
right to look at or get copies of your health information, with limited
exceptions. You must make the request in writing. You may obtain a form to
request access by using the contact information listed at the end of this
Notice. You may also request access by sending us a letter to the address at
the end of this Notice. If you request information that we maintain on paper,
we may provide photocopies. If you request information that we maintain electronically,
you have the right to an electronic copy. We will use the form and format you
request if readily producible. We will charge you a reasonable cost-based fee
for the cost
of supplies and labor of copying, and for postage if you want copies mailed to
Contact us using the information listed at the end of this Notice for an
explanation of our fee structure.
If you are denied a request for
access, you have the right to have the denial reviewed in accordance with the
requirements of applicable law.
Disclosure Accounting. With
the exception of certain disclosures, you have the right to receive an
accounting of disclosures of your health information in accordance with
applicable laws and regulations. To
request an accounting of disclosures of your health information, you must
submit your request in writing to the Privacy Official. 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 the additional requests.
Right to Request a Restriction. You have the right to request additional
restrictions on our use or disclosure of your PHI by submitting a written
request to the Privacy Official. Your written request must include (1) what
information you want to limit, (2) whether you want to limit our use,
disclosure or both, and (3) to whom you want the limits to apply. We are not required to agree to your request except in
the case where the disclosure is to a health plan for purposes of carrying out
payment or health care operations, and the information pertains solely to a
health care item or service for which you, or a person on your behalf (other
than the health plan), has paid our practice in full.
Alternative Communication. You have the
right to request that we communicate with you about your health information by
alternative means or at alternative locations. You must make your request in
writing. Your request must specify the alternative means or location, and
provide satisfactory explanation of how payments will be handled under the
alternative means or location you request. We will accommodate all reasonable
requests. However, if we are unable to contact you using the ways or locations
you have requested we may contact you using the information we have.
Amendment. 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 we agree to your request, we will amend your
record(s) and notify you of such. If we deny your request for an amendment, we
will provide you with a written explanation of why we denied it and explain
Notification of a Breach. You will receive notifications of breaches of your
unsecured protected health information as required by law.
Electronic Notice. You
may receive a paper copy of this Notice upon request, even if
you have agreed to receive this Notice electronically on our Web site or by
electronic mail (e-mail).
you want more information about our privacy practices or have questions or
concerns, please contact us.
you are concerned that we may have violated your privacy rights, or if 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.
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 Human Services.
Address: Todd R. VanderMeer D.D.S., P.C.
Attn: Privacy Official Phone:
1869 Porter St S.W.,
Wyoming, MI 49519 E-mail: firstname.lastname@example.org