NOTICE OF PRIVACY PRACTICES FOR
PROTECTED HEALTH INFORMATION
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!
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable information used or disclosed by this office in any form, pharm whether electronically, on paper, or orally are kept properly confidential. Such information may include documenting your symptoms, examination, consultations with other health professionals and test results, diagnosis, treatment and applying for future health care. It also includes billing documents for those services.
Example of uses of your health information for treatment purposes:
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 may share information with the specialist and obtain input.
Example of use of your health information for payment purposes:
Payment means such activities as obtaining reimbursement for services, confirming coverage, billing and collection activities, and utilization review. The health insurance company requests information from us regarding medical or dental care given. We will provide information to them about you and the care given at our office.
Example of use of your information for health care operations:
This includes the business aspects of running our practice such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal services and insurance. We will share information about you with such insurers or other business associates as necessary to obtain these services.
YOUR HEALTH INFORMATION RIGHTS
The health record we maintain and billing records are the physical property of the practice. The information in it , however belongs to you. You have a right to:
- Request a restriction on certain uses and disclosures of your health information by delivering the request in writing and with proof of identity to our office. We are not required to grant the request but we will comply with any request granted.
- Request that you be allowed to inspect and copy your health and billing record. You may exercise this request by delivering the request in writing and with proof of identity to our office.
- Appeal a denial of access to your protected health information except in certain circumstances
- Request that your health care record be amended to correct incomplete or incorrect information by delivering a written request with a proof of identity to our office
- File a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of you protected health information
- Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a written request and proof of identity to our office. An accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you or made at your request, or disclosures made to family members or friends in the course of providing care
- Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing and with proof of identity to our office
- Revoke authorization that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office
If you want to exercise any of the above rights, please contact Constance J. Elwell, CMM at 524 Maple Avenue, Linwood, NJ 08221 (609) 653-6300, in person or in writing during normal business hours. Constance will provide you with assistance on the steps to exercise your rights.
Our Office Responsibilities
The practice of Dr. David L. Sykes is required to :
- Maintain the privacy of your health information as required by law
- Provide you with a notice of our duties and privacy practices as to the information we collect and maintain about you
- Abide by the terms of this notice
- Notify 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 copy.
Other disclosures and uses
Unless 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. Unless you object we will leave protected health information on your answering machine, such as lab and biopsy results.
Communication with family
Using 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 persons involvement in your care or in payment for such care if you do not object or in an emergency.
Food and Drug Administration (FDA)
We may disclose to the FDA your protected health information relating to adverse events with respect to products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.
If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Worker’s Compensation.
As required by law, we may disclose your protected health information to the public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Abuse and Neglect
We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.
To request information or file a complaint
If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact Constance Elwell, CMM, Office Manager at (609) 653-6300 during Business hours.
Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to Constance Elwell, CMM, Office Manager. You may also file a complaint or request additional information about HIPAA by mailing it to:
The US Department of Health and Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington DC 20201
Toll Free: 1-877-696-6775
CERTIFICATION OF NON-MILITARY SERVICE
I hereby certify that I am neither in the military reserves nor am I in the active military service at this time, nor do I expect to be in the future.
IMPORTANT INFORMATION ABOUT YOUR RIGHT TO PRIVACY
A copy of David L. Sykes,DMD,LLC Notice of Privacy Practices has been made available to me. I understand that I have the right to review the notice, which is available in the office of David L. Sykes,DMD prior to signing this consent. David L. Sykes, DMD,LLC reserves the right to make changes to the Notice of Privacy Practices. Revised copies are available at the front reception area.
I ACKNOWLEDGE THAT I HAVE BEEN AFFORDED THE OPPURTUNITY TO CONSIDER DAVID L. SYKES, DMD,LLC NOTICE OF PRIVACY PRACTICES PRIOR TO SIGNING OF THIS CONSENT AND MAKING HEALTHCARE DECISIONS.