PRIVACY AGREEMENT

Baldwin Dental Group

Notice of Privacy Practices

This notice describes how medical/dental information about you may be used and disclosed and how you can get access to this information.  Please review it carefully.

Baldwin Dental Group values the privacy of your health information.  This Notice of Privacy Practices describes examples of how we may use or disclose your personal health information.  

OUR DUTIES

We are required by law to protect the privacy of your health information.  We are also required to give you this notice to tell you how we may disclose your personal health information.  We are required to abide by the terms of this Notice.  We may change the terms of our notice at any time.  Any new notice will be effective for all personal health information that we maintain at that time.  Our current Notice of Privacy Practices can be obtained at our reception desk for by calling (270-821-2800) or by asking that a copy be sent to you in the mail.

Personal Health Information That We May Collect

The personal health information that we collect may include your name, address, birth date, social security number, dental history, limited medical history, payment sources, the names of your caregivers (doctors, etc.) if needed and how to contact your family and others involved in your care.

When We May Use Or Disclose Your Personal Health Information

 Without Your Authorization

Treatment, Payment and Health Care Operations.  The following are examples of how we may disclose your personal health information to deliver treatment, obtain payment, and operate our programs and business:

• We may share information with other health care providers who are involved in your care such as physicians, outside consultants and other facilities to which you may be transferred.

• We may share information with our business associates who perform services for us (e.g. billing, audit services).  If we do share information with them, we will have a written contract that will obligate the business associate to protect the privacy of your personal health information.

• We may disclose your information to obtain payment.  This may include sharing information with your dental insurance as it makes payment decisions.  We may also disclose your information to another health care provider to help them obtain payment.

• We may contact you about your appointment.

• We may call you by name in the reception area.

• We may contact you about treatment options, other dental-related benefits and other products and services that we offer.

Required by Law.  We may use or disclose your personal health information as required by law.  The use or disclosure will be made in strict compliance with the law.

Contagious Diseases.  When permitted by law, we may disclose your information to a person who may have been exposed to a communicable disease.

Abuse or Neglect.  We may disclose your personal health information to a governmental agency authorized to receive such information if we believe that you have been a 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.

Legal Proceedings.  We may disclose your personal health information for judical and administrative proceedings, such as responding to a subpoena or court order.

Law Enforcement.  We may disclose your personal health information for law enforcement purposes, such as providing limited information to locate a missing person, to report certain types of wounds and to report crimes that occur on our property.

Coroners, Funeral Directors.  We disclose your information to a coroner or medical examiner in order for them to perform their legal duties such as making identification and determining cause of death.  We disclose your information to funeral directors to permit them to carry out their duties. 

Criminal Activity.  We may disclose personal health information if it is necessary for law enforcement authorities to identify or apprehend an individual.

Military Activity and National Security.  If you a member of the United States military, we may disclose your information as required by military command authorities.  We may disclose your personal health information for federal officials to conduct national security and intelligence activities, to protect the President or other specified people or to conduct special investigations.  We disclose information for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits.

Workers’ Compensation.  We may disclose your personal health information under workers’ compensation laws and other similar programs.

Inmates.  If you are in custody, we may disclose your personal health information to the correctional facility or the law enforcement official that maintains your custody.

YOUR AUTHORIZATION IS REQUIRED FOR OTHER USES AND DISCLOSURES

You must give us your written authorization before we disclose your personal health information for other uses.  You may revoke an authorization at any time by contacting our Privacy Officer.  A revocation will not apply to any action we have taken in reliance on the authorization.

YOU HAVE THE OPPORTUNITY TO AGREE OR OBJECT

You have the opportunity to agree or object to the use or disclosure of all or part of your personal health information as described below.

Others Involved In Your Healthcare.  Unless you object, we may disclose your information to a relative, a close friend, or any other person you identify.  We may also give out your information when it appears, under the circumstances, to be in your best interest to do so.

Disaster Relief.  We may disclose limited information to an authorized entity to assist in disaster relief efforts if we cannot contact you.

YOUR RIGHTS

Access to your information.  You may see and receive a copy of your personal health information.  In some cases, we may deny your request.  When required by law, we will give you an opportunity to have our denial reviewed.  Please contact our Privacy Officer if you have questions about access to your dental record.

Limits on what we use and disclose.  You may ask us to limit how we use and disclose your health information to provide treatment, to obtain payment, to operate our programs and business, and to communicate with your family, friends, and others you have identified.   Your request must state the specific restriction requested and to whom you want the restriction to apply.  We are not required to agree to that request.

Confidential communications.  We will accommodate reasonable requests.  However, we may require you to tell us how you will handle payment and give details about where and how to contact you.  We will not ask you why you make this request.  Pleae make this request in writing to our Privacy Officer.

Amend your personal health information.  You may ask that we amend your personal health information.  We may deny your request.  If we deny your request, you can appeal the denial in writing.  We will respond to your appeal in writing.  Please contact our Privacy Officer.

List of disclosures.  You have the right to receive a list of those who received your personal health information from us during the six years before your request.  We do not have to include what we disclosed:

• Before April 14, 2003

• To carry out treatment, payment and health care operations.

• To persons involved in your care.

• To prisons or their officers.

• For national security or intelligence purposes.

• To you or someone you have asked to speak for you.

• To those who get this information with your approval.

REPORTING A PROBLEM

If you believe we violated your privacy rights, you may complain by :

• Contacting our Privacy Officer.

• Contacting the Secretary of Health and Human Services.

We will not retaliate against anyone who makes a complaint.

ADDITIONAL INFORMATION

We may collect information that is not described above.  We may use and disclose your information in any manner that is consistent with the concepts described in this Notice or permitted by the privacy laws.  For additional information about our privacy policies, please contact our Privacy Officer.  This notice was published and becomes effective April 14, 2003.

NOTICE OF PRIVACE PRACTICES

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

The attached document is our Notice of Privacy Practices.  You may review it now or later.  At some point, you should read the Notice carefully because it explains:

1. How health care information about you is used.

2. That we may use and give out your health information to treat you, to get paid for uor services and to run our business.  We are not required to get your permission for these purposes. 

3. Other circumstances I which we may use or give out information about your health without asking for your permission.

4. Your rights about your health information, including your rights to:

• Have a copy of our Notice of Privacy Practices.

• Review and copy your health information.

• A list of how we give out your health information.

• Ask that we use a special address or telephone number to contact you.

• Ask for limits on how we use your health information.

• Ask for an amendment to your record if you feel it is not correct.

• File a complaint if you think your privacy rights have been violated.

Acknowledgment of Receipt:  I have received a copy of the Notice of Privacy Practices for the Baldwin Dental Group this ______ day of _________, 20__.

Signature: ___________________________________________________

Please print name: _____________________________________________

Relationship to the Patient: _______________________________________