DEBORAH TEKDOGAN D.D.S., LTD.
2805 CENTRAL STREET
EVANSTON, IL 60201
NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
(This notice describes how medical information about you may be used and disclosed and haw you can get access to this information.)
Please review it carefully!
With your consent, the practice is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services. This notice takes effect 01/15/05 and will remain in effect until we replace it.
Treatment: We may use and disclose your protected health information in order to provide , coordinated or manage you care or related, services. We may also disclose your protected health information to other dentists, physicians, healthcare services providers who are now or become involved in taking care of you.
Payment: We may use or disclose your protected health information in order to obtain payment for services we provide to you.
Healthcare Operations: We may use or disclose your health information as needed in connection with our healthcare operations, such as contacting you regarding an appointment, our practice's quality assessment and improvement, development of protocol and clinical guidelines, conduction training programs, credential- ing, medical review, legal and insurance services.
YOUR HEALTH INFORMATION RIGHTS:
The health records we maintain and billing records are the physical property of the practice. The information in it, however, belongs to you. You have the right to:
* Request a restriction on certain uses and disclosures of you health information by delivering the request in writing to our office. We are not required to grant the request by we will comply with any request granted;
* Obtain a paper copy of this Notice of Privacy Practices for Protected Health Information ("Notice") by making a request at our office;
* Request that you be allowed to inspect and copy your health record and billing record - you may exercise this right by delivering the request in writing to our office;
* Appeal a denial of access to your protected health information except in certain circumstances;
* Request that your health care record be amended to correct incomplete and incorrect information by delivering a written request to our office;
* File a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information;
* Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our office. An accounting will not include internal uses of information treatment, payment, or operations, disclosures made to you or made at your request, or disclosures made to family members or friends in the course of providing care;
* Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office: and,
* Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already bee taken by delivering a written revocation to our office.
The practice is required to:
* Maintain the privacy of our health information as required by law;
* Provide you with a notice of our duties and privacy practices as to the information we collect and maintain about you;
* Abide by the terms of this Notice;
* Notify you if we cannot accommodate a requested restriction or request; and
* Accommodate your reasonable request regarding methods to communicate health information with you.
We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our "Notice" or by visiting our office and picking up a copy.
TO REQUEST INFORMATION OR FILE A COMPLAINT:
If you have question, would like additional information, or want to report a problem regarding the handling of your information, you may contact us at 847 328-8500.
Additionally, if you believe your privacy, rights have been violated, you may file a written complaint at our office by delivering the written complaint to us. You may also file a complaint by mailing it or phoning the Secretary of Health and Human Services whose street address and phone number is 105 W. Adams Street, Chicago, IL 60603, 312 353-5160.
* We cannot, and will not require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the practice.
* We cannot, and will not, retaliate against you for filing a complaint with the Secretary.
OTHER DISCLOSURES AND USES:
Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general conditions, or your death.
COMMUNICATION WITH FAMILY:
Unless you object, we may disclose to a member of your family, a relative close friend or other person you identify, your protected health information that directly related to that person's involvement in your health care. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information to notify or assist in notifying a family member, personal representative or any other person that is responsible for your care of your location or general condition.
FEED AND DRUG ADMINISTRATION : (FDA)
We may disclose to the FDA your protected health information relating to adverse events with respect to products and product defects, or post-marketing surveillance information to enable product recalls. repairs, or replacements.
If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.
As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling diseases, injury, or disability.
ABUSE & NEGLECT:
We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.
If you are an inmate or in a correctional institution, we may disclose to the institution, or its agents, your protected health information necessary for your health and the health and safety of other individuals.
We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement.
Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.
We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by proper court order.
Other uses and disclosures besides those identified in the Notice will be made only as otherwise authorized by law or with your written authorization and you may revoke the authorization as previously provided.
If we maintain a website that provides information about our entity, this Notice will be on the website.