Notice of Privacy Practices

Carlos J. Rodríguez-Feo, DDS, PA Notice of Privacy Practices

Effective Date: September 30, 2009

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.

OUR OBLIGATIONS:

We have a commitment to protecting the privacy rights of our patients. In keeping with this commitment, and as required by law, we will:

· Obtain your consent to use and disclose records about your health and healthcare

· Maintain the privacy of protected health information (PHI);

· Give you this notice of our legal duties and privacy practices regarding health information about you; and

· Follow the terms of our notice of privacy practices that is currently in effect.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION:

When you receive services at Carlos J. Rodriguez-Feo, DDS, PA, you will be asked to sign an acknowledgement of this notice, which describes how we use and disclose information about you in ways that are permitted by federal law. The law provides for significant privacy protections of health information.

The following categories describe ways that we may use and disclose health information that identifies you (“Health Information”). Some of the categories include examples, but not every type of use or disclosure of Health Information in a category is listed. Except for the purposes described below, we will use and disclose Health Information only with additional written permission from you. If you give us permission to use or disclose Health Information for a purpose not discussed in this notice, you may revoke that permission at any time by sending a written request to our Privacy Officer at the address listed at the end of this notice.

a) For Treatment. We may use Health Information to treat you or provide you with health care services. We may disclose Health Information to doctors, nurses, technicians, or other personnel, including people outside our office who may be involved in your medical care. For example, we may tell your primary physician about the care we provided you or give Health Information to a specialist to provide you with additional services.

b) For Payment. We may use and disclose Health Information so that we or others may bill or receive payment from you, an insurance company or a third party for the treatment and services you receive. For example, we may give your health plan information about your treatment so that they will pay for such treatment. We also may tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.

c) For Health Care Operations. We may use and disclose Health Information for health care operations and administrative purposes. These uses and disclosures are necessary to make sure that all of our patients receive quality care and for our operation and management purposes. For example, we may use and disclose Health Information to review the treatment and services we provide to ensure that the care you receive is of the highest quality, for evaluating the way we communicate with our patients, or we may post thank-you notes or pictures that you send us. We may also share Health Information with other entities that have a relationship with you (for example, your health plan) for their health care operation activities.

d) Appointment Reminders, Treatment Alternatives, and Health-Related Benefits and Services. We may use and disclose Health Information to contact you as a reminder that you have an appointment with us. We also may use and disclose Health Information to tell you about treatment options or alternatives or health-related benefits and services that may be of interest to you.

e) Individuals Involved in Your Care or Payment for Your Care. We may disclose Health Information to a person, such as a family member or friend, who is involved in your medical care or payment for your care. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.

f) Research. Under certain circumstances, we may use and disclose Health Information for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication or treatment to those who received another, for the same condition. Before we use or disclose Health Information for research, though, the project will go through a special approval process. Even without special approval, we may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes, so long as they do not remove or take a copy of any Health Information.

SPECIAL CIRCUMSTANCES In accordance with applicable law, we may use or disclose your PHI without your permission, Consent or Authorization for the following purposes:

g) As Required by Law. We will disclose Health Information when required to do so by international, federal, state or local law.

h) To Avert a Serious Threat to Health or Safety. We may use and disclose Health Information when necessary to prevent or lessen a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, will be to someone who may be able to help prevent the threat.

i) Business Associates. We may disclose Health Information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. For example, we may use another company to perform billing services on our behalf. All of our business associates are obligated, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.

j) Organ and Tissue Donation. If you are an organ donor, we may release Health Information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary, to facilitate organ or tissue donation and transplantation.

k) HIV Test Results. If you received an HIV test and did not give us permission to use and disclose the results with your medical record, we will use and disclose the results of HIV tests that identify you only: (1) to provide you with health care services, for example, we may tell a specialist about your HIV status so the specialist can treat you; (2) when compiling or reviewing your records as part of routine billing; (3) if necessary to enable us to protect the quality of our services; (4) to child-placing or child-caring agencies, family foster homes, residential facilities or community-based care programs that are directly involved in placement, care, control or custody and who have a need to know such information; (5) to a sex or needle sharing partner in accordance with the law; (6) in accordance with a court order that specifically requires us to release HIV test results; and (7) in connection with organ donation.

l) Military and Veterans. If you are a member of the armed forces, we may release Health Information as required by military command authorities. We also may release Health Information to the appropriate foreign military authority if you are a member of a foreign military.

m) Workers’ Compensation. We may disclose Health Information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

n) Public Health Risks. We may disclose Health Information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; track certain products and monitor their use and effectiveness; notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and conduct medical surveillance of our office in certain limited circumstances concerning workplace illness or injury. We also may release Health Information to an appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence; however, we will only release this information if you agree or when we are required or authorized by law.

o) Health Oversight Activities. We may disclose Health Information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

p) Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose Health Information in response to a court or administrative order. We also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

q) Law Enforcement. We may release Health Information if asked by a law enforcement official for the following reasons: (1) in response to a court order, subpoena, warrant, summons or similar process; (2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; (3) about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; (4) about a death we believe may be the result of criminal conduct; (5) about criminal conduct on our premises; and (6) in emergency circumstances to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime.

r) Medical Examiners and Funeral Directors. We may release Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We also may release Health Information to funeral directors as necessary for their duties.

s) National Security and Intelligence Activities. We may release Health Information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law.

t) Protective Services for the President and Others. We may disclose Health Information to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations.

u) Inmates or Individuals in Custody. In the case of inmates of a correctional institution or that are under the custody of a law enforcement official, we may release Health Information to the appropriate correctional institution or law enforcement official. This release would be made only if necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; or (3) for the safety and security of the correctional institution

YOUR RIGHTS:

You have the following rights regarding Health Information we maintain about you:o:p

a) Right to Inspect and Copy. You have the right to inspect and copy Health Information that may be used to make decisions about your care or payment for your care by submitting a written request form.

b) Right to Amend. If you feel that Health Information we have is incorrect or incomplete, you may ask us to amend the information by submitting a written request form. You have the right to request an amendment for as long as the information is kept by or for our office. You must tell us the reason for your request.

c) Right to an Accounting of Non-routine Disclosures. You have the right to request an accounting of certain disclosures of Health Information we made by submitting a written request form.

d) Right to Request Restrictions. You have the right to request a restriction or limitation on the Health Information we use or disclose for treatment, payment, or health care operations by submitting a written request form. Please note that we will not grant requests for restrictions that pertain to your treatment. In addition, you have the right to request a limit on the Health Information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. For example, you could ask that we not share information about your surgery with your spouse. We are not required to agree to your request. If we agree, we will comply with your request unless we need to use the information in certain emergency treatment situations.

e) Right to Request Alternate Communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location by submitting a written request form. For example, you can ask that we contact you only by mail or at work. Your request must specify how or where you wish to be contacted. We will accommodate reasonable requests.

f) Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice during our office hours. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice. You may also obtain a copy of this notice at our website, www.JawSurgery.org.

HOW TO EXERCISE YOUR RIGHTS:

To exercise your rights described in this notice (other than to obtain a copy of this notice), you must send a request, in writing, to our Privacy Officer at the following address:

Privacy Officer, Carlos J. Rodríguez-Feo, DDS, PA, 6601 Southwest 80th Street, Suite 125, Miami, Florida 33143

CHANGES TO THIS NOTICE:

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for Health Information we already have as well as any information we receive in the future. We will post a copy of the current notice at our office. The notice will contain the effective date on the first page, in the top right-hand corner.

COMPLAINTS AND QUESTIONS:

If you believe your privacy rights have been violated, you may file a complaint with us or the Secretary of the U.S. Department of Health and Human Services. To file a complaint with our office, contact our Privacy Officer at the address listed above. All complaints must be made in writing. You will not be penalized for filing a complaint.

If you have any questions about this notice, please contact our Privacy Officer at (305) 665-3721