CLEBURNE FAMILY DENTISTRY
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED,
AND HOW YOU CAN GET ACCESS TO THIS INFROMATION. PLEASE REVIEW IT CAREFULLY.
Cleburne Family Dentistry
710 N. Nolan River Rd.
Cleburne, TX 76033
Cleburne Family Dentistry is required by law to maintain the privacy of your Protected Health Information
(PHI), and to provide individuals with notice of its legal duties and privacy practices currently in effect with
respect to PHI. This Notice describes how we may use and disclose your PHI for treatment, payment, and
for health care operations as well as for other purposes that are permitted or required by law. 45CFR ,„ij
Cleburne Family Dentistry reserves the right to change the terms of this Notice and make the new notice
provisions effective for all the PHI we maintain. If practice makes a material change to this Notice, we will
post the changes promptly on our website at www.cleburnefamilydentistry.com. A paper copy of this
Notice is available upon request.
This Notice of Privacy Practices became effective on April 14, 2003 and was amended on November 12,
Types of Uses and Disclosures of your PHI
"Treatment" — We will use and disclose your PHI to provide, coordinate or manager your dental health
care and any related services. We will also disclose PHI to other providers who may be treating you such
as a specialist.
"Payment" — We will use your PHI to obtain payment for the dental health care services provided. For
example, we may provide information to a health insurance company or business associate to obtain
payment for the treatment provided to you.
"Healthcare Operations" — We will use your PHI to support the management of our dental office. For
example, we may use information about you to conduct quality performance reviews regarding our
services or the performance of our staff. Additionally, we may obtain services from business associates
such as training programs, legal services, and insurance.
HITECH Act Breach Notification Requirements: The HITECH Act requires us to notify each individual
whose unsecured PHI has been, or is reasonable believed to have been accessed, acquired or disclosed
due to a breach. The HITECH Act Imposes a similar requirement on Business Associates. "Unsecured PHI"
refers to PHI that is not secured through the use of technologies or methodologies that render the PHI
unusable, unreadable, or indecipherable to authorized individuals.
Restriction of Disclosure: The HITECH Act restricts us from refusing an individual's request not to use or
disclose the individual's PHI in instances where the patient's services were paid out of pocket to prevent
the information from flowing to the health plan since no claim is being made against the third party payer.
Access to Electronic Heah,1 Records (EHRs): The HITECH Act expands the right of records access.
Individuals have the right to access their HER in an electronic format and to direct us to send the e-record
directly to a third party. We may only charge for the labor costs to transfer the information.
Expansion of Accounting of Disclosures: The HITECH Act removed the accounting of disclosures
exception of PHI to carry out treatment, payment and healthcare operations. All such disclosures must be
accounted for if the disclosure is made through an EHR.
We also will provide the individual with a list and
contact information for all relevant business associates to obtain and accounting of disclosures of PHI.
Prohibition on Sale of PHI: The HITECH Act prohibits covered entities and business associates from
receiving indirect or direct re-numeration in exchange for PHI without obtaining an authorization from the
individual, unless such an exchange meets one of the exceptions listed by the government.
Cleburne Family Dentistry's Responsibilities
Certain Uses or Disclosures: We will use and disclose your PHI when required to by federal, state or local
Appointment Reminders: We may contact you to provide appointment reminders via telephone or
postcards. We may contact you to provide information about treatment alternatives or other health-
related benefits and services that may be of interest to you.
Revocation: Other uses and disclosures will be made only with your written authorization and you may
revoke such authorization.
Public Health & Safety: We will use and disclose your PHI to public health authorities permitted to collect
or receive information for the purpose of controlling disease, injury or disability.
Individual Rights Request Restriction of Disclosures: You have the right to request restrictions on certain
uses and disclosures of PHI and under HIPAA, Cleburne Family Dentistry in not required to agree to that
restriction unless as clarified and defined by the HITECH Act.
Right to Receive Confidential Communications: You have the right to request confidential
communications. Please specify your preference of communication in writing to us such as your home
telephone, work telephone, mobile telephone, and/or email. We may provide relevant portions of your
PHI to a family member, relative, close friend or any other person you identify as being involved in your
dental care or payment.
Right to PHI: You have the right to inspect and copy the PHI that we maintain about you in our
designated record set for as long as we maintain the information. We may charge a fee for the costs of
copying, mailing, or other supplies used in fulfilling your request. Please contact the Privacy Officer
stating the reasoning that supports your request. We may deny the request if the information was not
created by our office or if the person who created it is no longer available to make this amendment.
Right to Accounting: You have the right to receive an accounting of disclosures of your health
information as required by law. Please submit a written request to our Privacy Officer.
Right to Paper Copy: You have a right to obtain a paper copy of the Notice of Privacy Practices.
Request Information or File a Complaint
If ypu have questions, would like additional information or want to report a problem regarding the
handling of your PHI, you may contact the Privacy Officer at:
Cleburne Family Dentistry
710 N. Nolan River Rd.
Cleburne, TX 76033
Phone (817) 645-3906 Fax: (817) 645-0275
Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our
office at the above address.
You may also file a complaint with the Secretary of Health and Human Services at:
U.S. Department of Health and Human Services
Office of Civil Rights
200 Independence Ave. SW Room 515 F HHH Building
Washington, DC 20201