Patient Privacy Policy
ORAL & MAXILLOFACIAL SURGERY OF ELKHART
NOTICE OF PRIVACY PRACTICES
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.
With your consent, this practice is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnosis, treatment, and applying for future care or treatment. It also includes billing documents for those services.
YOUR PRIVACY CHOICES The health record we maintain and billing records are the physical property of this practice. The information contained in it be longs to you. You may:
- Request a restriction on certain uses and disclosures of your information by delivering the request in writing to our office. We are not required to grant the request but will comply with reasonable requests;
- Obtain a paper copy of this Notice of Privacy Practices by making a request at our office;
- Request a copy of your health information and billing record by delivering the request in writing 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 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 your protected health information;
- Obtain an accounting of disclosures of your health information as required to be maintained by law by providing a written request 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 requests, 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 providing the request in writing to our office; and
- Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by providing a written revocation to our office.
OUR RESPONSIBILITIES This practice 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; and
- Accommodate your reasonable requests regarding methods to communicate health information with you.
OUR USES AND DISCLOSURES We reserve the right to amend, change, or eliminate provisions in our privacy practice and access practice 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 requesting a copy of our Notice.
OTHER USES AND DISCLOSURES We reserve the right to use or disclose your information in certain situations, including but not limited to the following:
- Unless you object in writing, we may use your 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;
- Using our best judgment, we may disclose to a family member, or other relative, close friend, or any other person you identify, health information relevant to that person’s involvement in your care or in payment for such care if you do not object in writing or in an emergency;
- 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 Worker’s 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 public health or legal authorities charged with preventing or controlling disease, injury, or disability;
- We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect;
- If you are an inmate of a correctional institution, we may disclose to the institution, or its agents, your protected health information necessary for your health and the health and safety of other individuals;
- We may disclose your information for law enforcement purpose as required by law, such as when required by a court order, or in cases involving felony prosecutions, or the extent an individual is in the custody of law enforcement;
- Federal law allows us to release your health information to appropriate health oversight agencies or for health oversight activities.
TO REQUEST INFORMATION, SUBMIT A REQUEST, OR FILE A COMPLAINT
You may submit a request or file a complaint in writing to our office at 3807 South Main St, Elkhart, IN 46517
If you believe your rights have been violated, you may submit a written complaint with the Secretary of Health and Human Services (SHHS) as a condition of receiving treatment at our office. We cannot, and will not, retaliate against you for filing a complaint with the SHHS.
