ASSOCIATED ORAL & MAXILLOFACIAL SURGEONS OF PEORIA, LTD.
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. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect (09/23/2013), and will remain in effect until we replace it.
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 reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU:
Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you. For example, we may disclose your health information to your general dentist or treating physician when applicable.
Payment: We may use and disclose your health information to obtain payment for services we provide to you. For example, your insurance plan may request and receive your health information in order to verify and process your insurance claims from our facility.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.
Individuals Involved in your Care: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so. We may use or 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 or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, 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. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
Public Health and Benefit Activities: We may use or disclose your health information when we are required to do so by law and when authorized by law for following kinds of public health and public benefit activities: to report disease and vital statistics, child or adult abuse, neglect or domestic violence; to avert a serious and imminent threat to health and safety; for health care oversight, such as activities of state insurance commissioners, licensing and peer review authorities and fraud prevention services; for research; in response to court and administrative orders and other lawful process; to law enforcement officials with regard to crime victims and criminal activities; to coroners, medical examiners, funeral directors, and organ procurement organizations; to the military, to federal officials for lawful intelligence, counterintelligence, and national security activities, and to correctional institutions and law enforcement regarding persons in lawful custody; and as authorized by state worker’s compensation laws.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).
Marketing Health-Related Services & Fundraising: We may use your health information to communicate with you about health related products, benefits, services, payment for those procedures and services, and treatment alternatives. We will not use your health information for marketing or fundraising communications without your written authorization. Once authorized, you may opt out of any of these communications at any time.
Plan Sponsors: If your insurance coverage is through an employer’s sponsored group plan, we may share summary health information with the plan sponsor.
Business Associates: We may disclose your health information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services. Our business associates are required to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract.
Data Breach Notification Purposes: We may use your contact information to provide legally required notices of unauthorized acquisition, access, or disclosure of your health information.
Additional Restrictions on Use and Disclosure: Certain federal and state laws may require special privacy protections that restrict the use and disclosure of certain health information, including highly confidential information about you. “Highly confidential information” may include confidential information under Federal laws governing alcohol and drug abuse information and genetic information as well as state laws that often protect the following types of information: HIV/AIDS; mental health; genetic tests; alcohol and drug abuse; sexually transmitted diseases and reproductive health information; and child or adult abuse or neglect, including sexual assault.
PATIENT RIGHTS
Access: You have the right to look at or get copies of your health information, with limited exceptions. We will use the format you request unless we cannot practicably do so. You should submit your request in writing to the contact listed at the end of this notice. We may charge you reasonable, cost based fees for a copy of your health information, for mailing the copy to you, and for preparing any summary or explanation of your health information you request. Use the contact information listed at the end of this notice for information on our fees.
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years. 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 requests. You should submit your request in writing to the contact information at the end of this notice.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information for treatment, payment or health care operations, or with family friends, and others you identify. Except in limited circumstance, we are not required to agree to your request. But if we do agree, we will abide by our agreement, except in a medical emergency or as required or authorized by law. We must agree to a restriction (except otherwise required by law)if: the disclosure is to a health plan for purposes of carrying out payment or health care operations (and not for purposes of carrying out treatment;) and the medical information pertains solely to the health care item or service for which the health care provider involved has been paid out of pocket in full by the patient. You should submit your request in writing to the contact information listed at the end of this notice.
Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. {You must make your request in writing.} Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.
Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.
Breach Notification: You have the right to receive notifications of breaches of your unsecured protected health information as required by law.
Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us.
If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.
We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
Contact Officer: Leigh Slavens, Practice Administrator
Telephone: (309) 682-1213
Fax: (309) 282-1355
E-mail: lslavens@aospeoria.com
Address: 2807 N. Knoxville Avenue, Peoria, Illinois 61604
