Clock Tower Dental Associates
NOTICE OF PRIVACY
THIS NOTICE DESCRIBES HOW HEALTH 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:
My Pledge Regarding Health Information
I understand that health information about you and your health is personal and I are committed to maintaining the confidentiality of your health information. I create and maintain a record of the care and services that you receive at my practice. I need this record to treat you and to comply with certain legal requirements. This notice applies to all of the records of your care generated by my practice, whether made by your personal doctor or by other personnel within my practice.
This notice advises you about the ways in which I may use and disclose health information about you. It also describes your rights to access and control your health information. 'Health Information' is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. This notice also describes your rights and explains certain obligations I have regarding the use and disclosure of health information.
I are required by law to:
- Make sure that health information that identifies you is kept private.
- Provide you with this notice of my legal duties and privacy with respect to health information about you.
- Follow the terms described in this notice.
I may change the terms of this notice at any time. The new notice will be effective for all protected health information that I maintain at that time. Upon your request, I will provide you with any revised Notice of Privacy by calling my office and requesting that a revised copy be sent to you in the mail, by asking for one at the time of your next office visit, or by accessing my website at:
110 New Hyde Park Road
Franklin Square, NY 11010
How I May Use and Disclose Health Information About You
The following categories describe different ways that I may use and disclose health information. For each category of uses or disclosures, I will explain what I mean and provide examples. Not every use or disclosure in a category will necessarily be listed below. However, all of the ways which I are permitted to use and disclose information will fall within one of the categories.
Treatment - I may use health information about you to provide you with health treatment or services. I may disclose health information about you to doctors, nurses, technicians, medical students, or other practice personnel who are involved in your health care and treatment. For example, a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. In addition, the doctor may need to inform the dietitian if you have diabetes so that I can arrange for you to receive information regarding appropriate meals. Different areas of the practice also may share health information about you in order to coordinate the different things you need, such as prescriptions, lab work and X-rays. I also may disclose health information about you to people outside the practice who may be involved in your health care after you leave my office, such as family members, clergy or others I may rely upon or ask to assist me in caring for you.
Payment - I may use and disclose health information about you so that the treatment and services which I provide to you at my practice, or at a hospital, ambulatory surgery center, nursing home or other site may be billed to and payment may be collected from you and/or your insurance company or other responsible third party. For example, I may need to provide to your health insurance plan information about the services which I provided to you at my practice, hospital or ambulatory surgery center, so that your health plan will pay me or reimburse you for the services. I may also advise your health insurance plan about a treatment you are going to receive in order to obtain prior approval or to determine whether your plan will cover the treatment.
Health Care Operations - I may use and disclose health information about you for my practice operations. These uses and disclosures are necessary to operate my practice and make sure that all of my patients receive quality care. For example, I may use health information to review my treatment and services and to evaluate the performance of my staff in caring for you. I may also combine health information about many practice patients to decide what additional services the practice should offer, what services are not needed, and whether certain new treatments are effective. I may also disclose information to doctors, nurses, technicians, health students, and other practice personnel for review and learning purposes. I may also combine the health information I have with health information from other practices to compare how I are doing and see where I can make improvements in the care and services that I offer. I may remove information that identifies you from this set of health information so others may use it to study health care and health care delivery without learning who the specific patients are.
Appointment Reminders - I may use and disclose health information in connection with my efforts to remind you that you have an appointment.
Treatment Alternatives - I may use and disclose health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. For example, I may use your information to determine whether you qualify for a nutritional counseling program.
Health-Related Benefits and Services - I may use and disclose health information to tell you about health-related benefits or services that may be of interest to you.
Fundraising Activities - I may use or disclose your demographic information and the dates that you received treatment from your doctor, as necessary, in order to contact you for fundraising activities supported by my practice. If you do not want to receive these materials, please contact my Privacy Contact and request that these fundraising materials not be sent to you.
Ambulatory Surgery Center Registry - If your care or services are performed at an ambulatory surgery center that is part of my practice, I may include certain limited information about you in the ambulatory surgery registry while you are a patient at the ambulatory surgery center. This information may include your name, location within the ambulatory surgery center, the facility directory, your general condition (e.g., fair, stable, etc.) and your religious affiliation. The registry information, except for your religious affiliation, may also be released to people who ask for you by name. Your religious affiliation may be given to a member of the clergy, even if they don't ask for you by name. This is so your family, friends and clergy can visit you in the ambulatory surgery center and generally be advised of how you are doing.
Individuals Involved in Your Care or Payment for Your Care - I may release health information about you to a friend or family member who is involved in your health care. I may also give information to someone who helps pay for your care. For example, a babysitter responsible for the care of a child may be provided with certain information about the treatment which I provided to the child. I may also advise your family or friends about your condition and that you are in a hospital, ambulatory surgery center or at my office. In addition, I may disclose health information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
Research - Under certain circumstances, I may use and disclose health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of health information, trying to balance the research needs with patients' need for privacy of their health information. Before I use or disclose health information for research, the project will have been approved through this research approval process. I may, however, disclose health information about you to people preparing to conduct a research project, for example, to help them look for patients with specific health needs, so long as the health information they review does not leave the practice. I will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at the practice.
SPECIAL SITUATIONS- Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object:
Emergencies - I may use or disclose your health information in an emergency treatment situation. If this happens, your doctor shall try to obtain your consent as soon as reasonably practicable after the delivery of treatment. If your doctor or another doctor in the practice is required by law to treat you and the doctor has attempted to obtain your consent but is unable to obtain your consent, he or she may still use or disclose your health information in order to treat you.
Communication Barriers - I may use and disclose your health information if your doctor or another doctor in the practice attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the doctor determines, using professional judgment, that you intend to consent to use or disclosure under the circumstances.
Coroners, Medical Examiners and Funeral Directors - I may release health information to a coroner or to a medical examiner. This may be necessary, for example, to identify a deceased person or to determine the cause of death. I may also release health information about patients to funeral directors as necessary to carry out their duties
Organ and Tissue Donation - If you are an organ donor, I 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.
As Required By Law - I will disclose your health information when required to do so by federal, state or local law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law.
Legal Proceedings - If you are involved in a lawsuit or a dispute, I may disclose health information about you in response to a court or administrative order. I may also disclose health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if required by law or if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
Public Health - I may disclose health information about you for public health activities. These activities generally include the following:
- To prevent or control disease, injury or disability.
- To report births and deaths.
- To report child abuse or neglect.
- To report reactions to medications or problems with products.
- To notify people of recalls of products they may be using.
- To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
- To notify the appropriate government authority if I believe a patient has been the victim of abuse, neglect or domestic violence. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.
To Avert a Serious Threat to Health or Safety - I may use and disclose health information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
Law Enforcement - I will disclose health information when required to do so for law enforcement purposes. These law enforcement purposes include:
- Legal processes and otherwise required by law.
- Limited information requests for identification and location purposes.
- Pertaining to victims of a crime.
- Suspicion that death has occurred as a result of criminal conduct.
- In the event that a crime occurs on the premises of the practice.
- Medical emergency (not on the practice's premises) and it is likely that a crime has occurred.
Criminal Activity - Consistent with applicable federal and state laws, I may disclose your health information, if I believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. I may also disclose health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
Inmates - If you are an inmate of a correctional facility or under the custody of a law enforcement official, I may release health information about you to the correctional facility or law enforcement official. This release would be necessary
- For the institution to provide you with health care.
- To protect your health and safety or the health and safety of others.
- For the safety and security of the correctional institution.
National Security and Intelligence Activities - I may release health information about you to authorized federal officials for intelligence, counterintelligence, protection of the President, other authorized persons or foreign heads of state, for purpose of determining your own security clearance and other national security activities authorized by law.
Military and Veterans - If you are a member of the armed forces, I may release health information about you as required by military command authorities. I may also release health information about foreign military personnel to the appropriate foreign military authority. If you are a member of the Armed Forces, I may disclose health information about you to the Department of Veterans Affairs upon your separation or discharge from military services. This disclosure is necessary for the Department of Veterans Affairs to determine whether you are eligible for certain benefits.
Workers' Compensation - I may release health information about you to comply with worker's compensation laws or similar programs. These programs provide benefits for work-related injuries or illness.
Health Oversight Activities - I 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. Under the law, I must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine my compliance with the requirements of Section 164.500 et. seq.
Your Rights Regarding Health Information About You
You have the following rights regarding health information I maintain about you:
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. Usually, this includes health and billing records and any other records that your doctor and the practice use for making decisions about you. I may deny your request to inspect and copy in certain limited circumstances. Under federal law, you may not inspect or copy:
- Psychotherapy notes.
- Information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding.
- Health information that is subject to law that prohibits access to health information.
If you are denied access to health information, you may request that the denial be reviewed. Another licensed health care professional chosen by the practice will review your request and the denial. The person conducting the review will not be the person who denied your request. I will comply with the outcome of the review.
To inspect and copy health information that may be used to make decisions about you, you must submit your request in writing to Ramin Rayhan. If you request a copy of the information, I may charge a fee as permitted by state law for the costs of copying, mailing or other supplies associated with your request.
Right to Amend - If you feel that health information I have about you is incorrect or incomplete you have the right to request an amendment for as long as the information is maintained the practice. Your request must be made in writing to my Privacy Contact and you must provide a reason that supports your request. I may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, I may deny your request if you ask me to amend information that:
- Was not created by me, unless the person or entity that created the information is no longer available to make the amendment.
- Is not part of the health information maintained by the practice.
- Is not part of the information which you would be permitted to inspect and copy.
- Is accurate and complete.
Right to Request Restrictions - You have the right to request a restriction or limitation on the health information I use or disclose about you for treatment, payment or health care operations. You also have the right to request a limit on the health information I 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 I not use or disclose information about a surgery that you had. Your request must be made in writing to my Privacy Contact and you must tell me
- What information you want to limit.
- Whether you want to limit my use, disclosure or both.
- To whom you want the limits to apply, for example, disclosures to your spouse.
The practice is not required to agree to your request. If your doctor believes it is in your best interest to permit the use and disclosure of your health information, then your health information will not be restricted. If I do agree, I will comply with your request unless the information is needed to provide you with emergency treatment. With this in mind, please discuss any restriction you wish to request with your doctor.
Right to an Accounting of Disclosures - You have the right to request an "accounting of disclosures." This is a list of the disclosures I made of health information about you. This right applies to disclosures other than purposes of treatment, payment or health care operations as described in this Notice of Privacy. It excludes disclosures I may have made to you, for a facility directory, to family members or friends involved in your care, or for notification purposes. Your request must be made in writing to my Privacy Contact and must indicate a time-period that may not be longer than six years and may not include dates prior to April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be provided at no cost to you. For additional lists, I may charge you for the costs of providing the list. I will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Confidential Communications - You have the right to request that I communicate with you about health matters in an alternative way or at an alternative location. For example, you can ask that I only contact you at work or by mail. I will accommodate reasonable requests and I will not request an explanation for your request. Please make this request in writing to my Privacy Contact.
Right to a Paper Copy of This Notice - You have the right to a paper copy of this notice, even if you have agreed to receive this notice electronically. You may print a copy of this notice or ask me to provide you with a copy of this notice at any time.
If you believe your privacy rights have been violated, you may file a complaint with the practice or with the Secretary of the Department of Health and Human Services. All complaints must be made in writing. You will not be penalized for filing a complaint.
To file a complaint with the practice, contact:
Other Uses of Health Information
Other uses and disclosures of health information not covered by this notice or the laws that apply to me will be made only with your written permission. If you provide me permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, I will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that I are unable to take back any disclosures I have already made with your permission, and that I are required to retain my records of the care that I provided to you.
This notice was published and becomes effective on November 2, 2016.
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