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 PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO US.
We are required by applicable federal and state laws to maintain the privacy of your protected health information. We are also required to give you this notice about our privacy practices, our legal duties, and your rights concerning your protected health information. We must follow the privacy practices described in this notice while it is in effect.
We reserve the right to change our privacy practices and the terms of this notice at any time, provided that such changes are permitted by applicable law. We reserve the right to make changes effective for all protected health information we maintain, including information created or received before the changes were made.
You may request a copy of this notice at any time. For more information about our privacy practices or for additional copies, please contact us using the information listed at the end of this notice.
We will use and disclose your protected health information for treatment, payment, and health care operations. The following examples describe the types of uses and disclosures that may occur. These examples are not exhaustive.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your healthcare and any related services, including coordination with third parties involved in your care such as specialists, laboratories, or other treating providers.
Payment: Your protected health information will be used as needed to obtain payment for healthcare services, including eligibility determinations, coverage reviews, and utilization review activities required by your insurance plan.
Health Care Operations: We may use or disclose your protected health information as needed to conduct business and operational activities including quality assessment, employee review, student training, licensing, and other operational activities. For example, we may use a sign-in sheet at the front desk, call you by name in the waiting room, or contact you by phone or mail to remind you of an upcoming appointment.
We will share your protected health information with third party business associates that perform services on behalf of our practice, such as billing or transcription. Any such arrangement will be governed by a written contract protecting the privacy of your information.
We may use your protected health information to provide you with information about treatment alternatives or other health-related services that may be of interest to you. You may contact us at any time to request that such materials not be sent to you.
Uses and Disclosures Based on Your Written Authorization: Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke any authorization in writing at any time. Your revocation will not affect uses or disclosures already made while the authorization was in effect.
Others Involved in Your Care: Unless you object, we may disclose your protected health information to a family member, relative, or close friend directly involved in your care. We may also use or disclose protected health information to notify family members or personal representatives of your location, general condition, or death.
Marketing: We may contact you with information about treatment alternatives that may be of interest to you. You may opt out of receiving such communications at any time by contacting us using the information at the end of this notice.
Research; Death; Organ Donation: We may use or disclose your protected health information for research purposes in limited circumstances, or disclose information of a deceased person to a coroner, medical examiner, funeral director, or organ procurement organization as permitted by law.
Public Health and Safety: We may disclose your protected health information to the extent necessary to avert a serious and imminent threat to health or safety, or to authorized government agencies for public health purposes.
Health Oversight: We may disclose protected health information to health oversight agencies for activities authorized by law, including audits, investigations, and inspections.
Abuse or Neglect: We may disclose your protected health information to a public health authority authorized to receive reports of child abuse or neglect, or if we believe you have been a victim of abuse, neglect, or domestic violence, consistent with applicable federal and state law.
Food and Drug Administration: We may disclose your protected health information as required by the FDA for reporting adverse events, product defects, product tracking, recalls, or post-marketing surveillance.
Criminal Activity and Law Enforcement: We may disclose your protected health information consistent with applicable law when necessary to prevent a serious threat to health or safety, or in response to lawful law enforcement requests including court orders, warrants, subpoenas, or grand jury requests.
Required by Law: We will disclose your protected health information when required to do so by law, including to the U.S. Department of Health and Human Services for compliance determinations, and as authorized by workers’ compensation or similar laws.
Access: You have the right to review or obtain copies of your protected health information, with limited exceptions. Requests must be made in writing. Copying fees of $25.00 per page or $10.00 per hour, plus postage if applicable, may apply. A summary or explanation may be prepared for a fee. Contact us for details.
Accounting of Disclosures: You have the right to receive a list of instances in which we disclosed your protected health information for purposes other than treatment, payment, or health care operations. We will provide the date, recipient, description, and reason for each disclosure. A reasonable fee may apply for requests made more than once within a 12-month period.
Restriction Requests: You have the right to request additional restrictions on the use or disclosure of your protected health information. We are not required to agree to such requests, but if we do, we will honor the agreement in writing except in an emergency.
Confidential Communication: You have the right to request that we communicate with you by alternative means or at an alternative location. Requests must be made in writing and must be reasonable and permit us to continue billing and collecting payment.
Amendment: You have the right to request an amendment to your protected health information. Requests must be in writing and include an explanation of why the amendment is warranted. We may deny requests under certain circumstances and will provide a written explanation if we do so.
Electronic Notice: If you received this notice electronically, you are entitled to receive it in written form upon request.
If you have questions about our privacy practices or believe your privacy rights have been violated, please contact us. You also have the right to submit a written complaint to the U.S. Department of Health and Human Services. We will not retaliate against you in any way for filing a complaint.
Contact Person: Dr. Stacey Zaikoski Phone: 937-293-6387 Address: 5671 Far Hills Ave, Dayton, OH 45429 Email: office@thelionstooth.com
This notice describes the privacy practices of Lion’s Tooth Pediatric Dentistry and Orthodontics and how we may use and disclose protected health information about our patients. Protected health information is information that may identify a patient and that relates to their past, present, or future physical or mental health, condition, or related healthcare services. We are required by law to maintain the privacy of this information and to provide patients with notice of our legal duties and privacy practices. This notice also describes patient rights to access and control protected health information.
