PRIVACY PRACTICES

PRIVACY PRACTICES

I acknowledge that I have received a copy of the Statement of Privacy Practices for the office of Reagin Orthodontics. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.

Reagin Orthodontics reserves the right to change the privacy practices that are described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed to me.

ADDITIONAL DISCLOSURE AUTHORITY

In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below.

Any member of my immediate family: YesNo
Spouse only: YesNo
OTHER (please specify): YesNo
I give my permission to Dr. Reagin to use my and or my child’s picture on their website for educational purposes.

NOTICE OF PRIVACY PRACTICES

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.

OUR OBLIGATIONS:

We are required by law to:
● Maintain the privacy of protected health information
● Give you this notice of our legal duties and privacy practices regarding health information concerning you
● Follow the terms of our notice that is currently in effect

USES AND DISCLOSURE OF HEALTH INFORMATION

Described as follows are the ways we may use and disclose health information that identifies you. Except for the following purposes, we will use and disclose health information only with your written permission.

Treatment: We may use or disclose your health information to a dentist or other healthcare provider providing treatment to you.
Payment: We may use or disclose your health information to obtain payment for services we provide to you.
Your Authorization: We may use and disclose health information for your treatment and to provide you with treatment with related health care services. We may also use and disclose your health information to provide you with information regarding your treatment such as voicemail messages, letters or emails. Persons Involved In Care: We may use and disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition or death. If you are present, then prior to use of disclosure of your health information, we will provide you with the opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstance, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare.
Public Health Risk: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of
others.
Health Care Operations: We may use and disclose health information for health care operation purposes. These uses and disclosures are necessary to make sure that all our patients receive quality care and to operate and manage of our office
Appointment Reminders: we may use and disclose your health information to provide you with appointment reminders such as voicemail messages, postcards, or letters. As required by law: We will disclose health information when required to do so by international, federal, state or local
law.
PATIENT RIGHTS:
Access: you have the right to look at or get copies of your health information, with limited exceptions. You must request in writing and allow 72 hours to obtain access to your health information. We will charge you a reasonable cost bases fee for expenses and staff time.
Disclosure Accounting: You have the right to request in writing a list of instances in which we may disclose your health information for purposes, other than treatment, payment, healthcare operations and certain other activities. If you request this accounting more than once in a 12 month period, we may charge you a reasonable, cost-based fee for responding to these additional request.
Restriction: You have the right to request in writing that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
Right to amend: If you feel that health information we have is incorrect or incomplete, you may request in writing an amendment for as long as the information is kept for our office. We may deny your request under certain circumstances.
Right to Request Confidential Communication: You have the right to request that we communicate with you about
medical matters in a certain way or in a certain area. To request confidential communication, you must put your request in writing. Your request must specify how or where you wish to be contacted. We will accommodate a reasonable request.
CHANGES TO THIS NOTICE
We reserve the right to revise this notice and make the new notice apply to all health information we already have as well as any information we receive in the future

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