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,
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
Notification
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.
Workers Compensation
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.
Public Health
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
(202) 619-0257
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.
___________________
_________________________________________
Date
Signature
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.
____________________________________________
_____________________
SIGNATURE
DATE |
