Heartland Endodontics & Periodontics logo

Michael G. Kirsch, DDS, MS

NOTICE OF PRIVACY PRACTICES FOR HEARTLAND PERIODONTICS

Heartland Periodontics, PA has always been concerned with protecting personal health information and the confidentiality of that information. New Federal (HIPAA – Health Insurance Portability and Accountability Act) laws have been enacted to further insure that information transmitted via computer or other electronic pathways is also protected and to inform you the patient as to how this information may be used and disclosed.

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Introduction

Heartland Periodontics, PA is committed to treating and using protected health information about you responsibly. This Notice of Health Information Practices describes the personal information we collect, and how or when we use or disclose that information. It also describes your rights as they relate to your protected health information. This Notice is effective April 14, 2003 and applies to all protected health information as defined by State and Federal regulations.

Understanding Your Health Record/Information

Each time you visit Heartland Periodontics, PA a record of your visit is made. Typically, this record contains an updated medical history, review of medications, symptoms, radiographs (x-rays), examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a

  • Basis for planning your care and treatments.
  • Means of communication among the many health professionals who contribute to your care.
  • Legal document describing the care you have received.
  • Means by which you or a third-party payer can verify that services billed were actually provided.
  • A tool in educating health professionals.
  • A source of information for public health officials charged with improving the health of this state and the nation.
  • A source of data for our planning and marketing.
  • A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.

Understanding what is in your record and how your health information is used helps you to ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.

Patients Health Information Rights

You have the right to:

  • Obtain a paper copy of this notice of information practices upon request.
  • Inspect and obtain a copy of your health record as provided for in 45 CFR 164.528
  • Amend your health record as provided in 45 CFR 164.528,
  • Obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528
  • Request communications of your health information by alternative means or at alternative locations
  • Request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.528
  • Revoke your consent or authorization to use or disclose health information except to the extent that action has already been taken.

Our Responsibilities

Heartland Periodontics, PA is required to:

  • Maintain the privacy of your health information
  • Provide you with this notice as to our legal duties and privacy practices with respect to information we collect and maintain about you
  • Abide by the terms of this notice,
  • Notify you if we are unable to agree to a requested restriction, and
  • Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

We reserve the right to change our privacy practice and the terms of this Notice at any time provided such changes are applicable by law. We shall make the new provisions effective for all protected health information we maintain. Should our information practices change, we will change this Notice and make the new Notice available upon request. You may request a copy of our Notice of Privacy Policies at any time.

We will not use or disclose your health information without your authorization, except as described in this notice. We will also discontinue using or disclosing your health information after we have received a written revocation of the authorization according to the procedures included in the authorization.

Business Associates: There are some services provided in our organization through contacts with business associates. Examples include companies for electronic insurance claims submission, and laboratory tests. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do and/or bill you or your third-party payer for services rendered. Business associates and other third-parties (if any) receiving personal health information are prohibited from re-disclosing it unless required to do so by law or the patient (or patients legal representative) gives prior express written consent to the re-disclosure. Nothing in the Business associate agreement is intended to, or shall it be construed to allow the business associate to violate this re-disclosure prohibition.

Examples of Disclosures for Treatment Payment and Health Operations

We will use your health information for treatment. For example, information obtained by an assistant, hygienist, dentist, or other member of your health care team will be recorded in your record and used to determine the course of treatment that should work best for you. Your dentist will document in your record his or her expectations of the members of your health care team. Members of your health care team will then record the actions they took and their observations. In that way, the dentist will know how you are responding to treatment.

We will use your health information for regular health operations. For example: Members of the dental health team, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the dental care and services we provide. We will also provide your restorative dentist, physician, or subsequent health care provider with various reports that should assist him or her in treating you while they provide co-therapy and/or subsequent treatment needs.

Super-confidential information regarding HIV testing, results, alcohol or substance abuse diagnosis and treatment, or psychotherapy and mental health records will NOT be disclosed unless you have signed our consent form specifically stating the type of super-confidential information we are allowed to disclose. This information may only be released if authorized under Special Rules (e.g. we are required by law to disclose it). We will comply with state and federal law that required us to warn the recipient in writing that re-disclosure is prohibited.

We will use your health information for payment. For example: A bill may be sent to you or a third-party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures, and supplies used.

Notification/Communication with family: Health professionals, using their best judgment, may disclose to a family member, or other relative, close personal friend or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.

Courtesy Contacts: We will remind you of a scheduled appointment or that it is time for you to contact us and make an appointment. Additionally, we may contact you to follow up on your care and inform you of treatment options or services that may be of interest to you or your family. These communications are an important part of our philosophy of partnering with our patients to be sure they receive the best preventive and restorative care modern dentistry can provide. They may include postcards, folding postcards, letters, telephone reminders, or electronic reminders such as e-mail (unless you tell us that you do not want to receive these reminders).

Workers Compensation: We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

Public Health and National Security: Personal health information regarding communicable diseases or adverse incidents will be disclosed to public health agencies only in accordance with the law.

Education and Research: Personal health information and clinical photographs will be disclosed for educational research only after it has been de-identified or as otherwise authorized in accordance with the law.

Correctional Institution: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof health information necessary for your health and the health and safety of other individuals.

Domestic Violence, Crime, Missing persons, and Medical Examiners, Law enforcement: Personal health information will be disclosed only in accordance with the applicable law.

For More Information or to Report a Problem: If you have questions and would like additional information, you may contact the designated Medical Records Custodian.

If you believe your privacy rights have been violated you can file a complaint with Heartland Periodontics, PA Privacy Officer or with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either the Privacy Officer or the Office for Civil Rights. The address for the OCR is listed below:

Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Room 509F, HHH Building
Washington, DC 20201

NOTICE OF PRIVACY POLICIES

HEARTLAND PERIODONTICS, PA

Michael G. Kirsch, DDS, MS