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

If you have any questions about this Notice please contact the Privacy Officer at
303-217-2377 or PrivacyOfficer@clearchoice.com

This Notice of Privacy Practices describes how we protect your health information and what rights you have regarding your health information. “Protected health information” is information about you, including demographic and financial information, that may identify you and that relates to your past, present, or future physical or mental health condition and related health and dental care services.

We are required by law to maintain the privacy of your protected health information, to provide you with and to abide by the terms of this Notice of Privacy Practices and to notify you of a breach of unsecured protected health information. We may change the terms of our Notice at any time. The new Notice will be effective for all protected health information that we maintain at that time.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION WITHOUT YOUR PERMISSION

We may use and disclose your protected health information for certain purposes without your authorization, including the following:

Treatment: We may use and disclose your protected health information to provide, coordinate, or manage your treatment. This includes the coordination or management of your health care with another provider. For example, we may use or disclose your information to schedule an appointment for you, to perform a medical or dental exam, to perform diagnostic tests, to discuss your plan of care or to prescribe medications. We may also disclose your information to another provider who cares for you, such as a physician who is treating you or another dentist. Your protected health information may be provided to a physician or dentist to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

We also may call, write, or email to remind you of routine scheduled appointments or referral appointments. We may also contact you to notify you of other treatments or services available that might help you.

Payment: We may use or disclose your protected health information to obtain payment for health care services we provided to you.

Health Care Operations: We may use or disclose your protected health information for certain administrative and managerial activities that are necessary to support the business activities of the Practice. For example, we may conduct quality assessment and improvement activities, employee review activities, training of medical/dental students, and licensing.

Others involved in Your Health Care or Payment for Your Care: Unless you instruct us not to, we may disclose your protected health information to a member of your family, a close friend, or any other person you identify who is involved in your medical and dental care.

Other Uses and Disclosures: In some limited situations and if certain conditions are met, we may also use or disclose your protected health information without your permission. Not all of these situations apply to us and some may never occur at all. Such permitted uses and disclosures are:

  • when state or federal law requires that certain information be reported for a specific purpose;
  • for public health activities and purposes, such as contagious disease reporting, investigation or surveillance and notices to and from the federal Food and Drug Administration regarding drugs or dental devices;
  • for health oversight activities, such as licensing dentists, audits, investigations, and inspections;
  • to governmental authorities about victims of abuse, neglect, or domestic violence;
  • for judicial or administrative proceedings, such as in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a subpoena, discovery request, or other lawful process.
  • for law enforcement purposes, such as to provide information about someone who is or was suspected to be a victim of a crime or to report information about a crime;
  • disclosures of de-identified information;
  • disclosures of a limited date set for research, public health, or health care operations;
  • to a medical examiner or coroner to identify a dead person or to determine the cause of death, or to funeral directors to aid in burial, or to organizations that handle organ or tissue donations;
  • for health related research that has been approved by an institutional review board or its equivalent;
  • for specialized government functions, such as for protection of the president or high ranking government officials, for lawful national intelligence purposes, for military purposes, or for evaluation and health of members of the foreign service;
  • disclosures related to workers’ compensation programs;
  • incidental disclosures that are an unavoidable by-product of permitted uses or disclosures; and
  • disclosures to “business associates” who perform health care operations for us and who agree to comply with privacy and security laws and regulations that apply to them.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION WITH YOUR PERMISSION

Before we can use or disclose your protected health information in a manner which is not described above, we must first obtain your written authorization. For example, most uses and disclosures of psychotherapy notes and of your health information for marketing purposes and for the sale of your health information require your written authorization. You may revoke this authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization, except to the extent we have relied on it. You may obtain a Revocation of Authorization form from the Privacy Officer and submit it to the address below.

Education and Teaching.

We may use and disclose your protected health information for purposes of teaching dentists, dental assistants and staff about our clinical and non-clinical practices and techniques. The purpose of such use and disclosure is to improve the knowledge and expertise of those who provide dental implant and prosthetic services or provide supporting services. Other dentists or manufacturer representative may be present during your treatment to observe or assist with equipment or materials, unless you object. This disclosure may include the use of photographs or videos taken before, during and after treatment as permitted by law.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

The following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights. You can request any of these rights by contacting our Privacy Officer at the telephone number or email shown at the beginning of this Notice.

Access to your records. You have the right to look at or order a copy of your medical records that we maintain. Except in a few limited situations, you will be able to review or have a copy of your health information within 30 days of your request. If we deny your request, we will send you a written explanation and instructions about how to get an impartial review of our denial if one is legally available. By law, we can have one 30 day extension to respond to your request if we send you a written notice of the extension. If we have information about you in electronic format, we will provide it to you in an electronic format. As permitted by federal and state law, we may charge you a reasonable copy fee for a copy of your records.

Restriction of your protected health information. You may request restrictions on our use and disclosure of your health information for treatment, payment or health care operations. Except as described in the next sentence, we do not have to agree to do this, but if we agree, we must honor the restrictions that you want. We are required by law to agree to your request to restrict disclosure of your protected health information to a health insurance plan for payment or health care operations purposes if the protected health information pertains solely to services that you have paid for out-of-pocket.

Confidential communications. You may ask us to communicate with you in a confidential way. We will accommodate any reasonable request for you to receive your protected health information by alternative means of communication or at an alternative location if you pay us for any extra cost. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Officer.

Amendment to your protected health information. You may request an amendment of your protected health information if you think it is incorrect or inaccurate. If we agree, we will amend the information within 60 days of your request. We will send the corrected information to persons who we know received the wrong information and others who you specify. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. We will include both your statement of disagreement and our rebuttal in your medical record. Please contact our Privacy Officer if you have questions about amending your medical record.

Accounting of certain disclosures of your protected health information. You may request a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want). By law this list will not include: disclosures for purposes other than treatment, payment, or health care operations (unless we have made disclosures from an electronic health record), disclosures made with your authorization, disclosures required by law, and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 30 days but by law we can have one 30 day extension if we notify you in writing of the extension. Your right to receive this information is subject to certain exceptions, restrictions, and limitations.

Additional copies of this Notice. You may request additional copies of this Notice of Privacy Practices even if you have agreed to accept this Notice electronically.

Notice of a Breach. We are required by law to notify you if there is ever a data breach that involves your protected health information.

COMPLAINTS

If you believe that your privacy rights have been violated, you may file a complaint with us and/or the U.S. Department of Health and Human Services. For more information on how to file a written complaint, call the Privacy Officer at the number listed above. Your privacy is one of our greatest concerns and there is never any penalty to you if you choose to file a complaint.

The contact information for the U.S. Dept. of Health and Human Services is listed below:

Office for Civil Rights
U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201
www.hhs.gov/ocr/civilrights/complaints/index.html

CHANGES TO THIS NOTICE

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We will provide you with a copy of the new Notice whenever we make a material change to the privacy practices described in this Notice. You may request a copy of the Notice at any time by contacting the Privacy Officer at the number listed above.

EFFECTIVE DATE

This Notice is effective June 5, 2017.

If you want more information about our privacy practices, contact the Privacy Officer at the telephone number or email listed at the beginning of this Notice.