THIS NOTICE DESCRIBES HOW MEDICAL 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 MEDICAL INFORMATION IS
IMPORTANT TO US.
Our Legal Duty
We are required by applicable federal and state laws to maintain the privacy
of your protected health information. We are also required to give you this
notice about our privacy practices, our legal duties, and your rights
concerning your protected health information. We must follow the privacy
practices that are described in this notice while it is in effect. This
notice takes effect April 14, 2003, 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 that 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 protected healthin formation
that we maintain, including medical information we created or received
before we made the changes.
You may request a copy of our notice (or any subsequent revised 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.
Uses and Disclosures of Protected Health Information
We will use and disclose your protected health information about you for
treatment, payment, and health care operations. Following are examples of
the types of uses and disclosures of your protected health care information
that may occur. These examples are not meant to be exhaustive, but to
describe the types of uses and disclosures that maybe made by our office.
Treatment: We will use and disclose your protected health information to
provide, coordinate or manage your healthcare and any related services. This
includes the coordination or management of your health care with a third
party. For example, we would disclose your protected health information, as
necessary, to a home health agency that provides care to you. We will also
disclose protected health information to other physicians who may be
treating you. For example, your protected health information may be provided
to a physician to whom you have been referred to ensure that the physician
has the necessary information to diagnose or treat you.
In addition, we may disclose your protected health information from time to
time to another physician or health care provider (e.g., a specialist or
laboratory)who, at the request of your physician, becomes involved in your
care by providing assistance with your health care diagnosis or treatment to
your physician.
Payment: Your protected health information will be used, as needed, to
obtain payment for your health care services. This may include certain
activities that your health insurance plan may undertake before it approves
or pays for the health care services we recommend for you, such as: making a
determination of eligibility or coverage for insurance benefits, reviewing
services provided to you for protected health necessity, and undertaking
utilization review activities. For example, obtaining approval for a
hospital stay may require that your relevant protected health information be
disclosed to the health plan to obtain approval for the hospital admission.
Health Care Operations: We may use or disclose, as needed, your protected
health information in order to conduct certain business and operational
activities. These activities include, but are not limited to, quality
assessment activities, employee review activities, training of students,
licensing, and conducting or arranging for other business activities.
For example, we may use a sign-in sheet at the registration desk where you
will be asked to sign your name. We may also call you by name in the waiting
room when your doctor is ready to see you. We may use or disclose your
protected health information, as necessary, to contact you by telephone or
mail to remind you of your appointment.
We will share your protected health information with third party "business
associates" that perform various activities (e.g., billing, transcription
services) for the practice. Whenever an arrangement between our office and a
business associate involves the use or disclosure of your protected health
information, we will have a written contract that contains terms that will
protect the privacy of your protected health information.
We may use or disclose your protected health information, as necessary, to
provide you with information about treatment alternatives or other
health-related benefits and services that may be of interest to you. We may
also use and disclose your protected health information for other marketing
activities. For example, your name and address may be used to send you a
newsletter about our practice and the services we offer. We may also send
you information about products or services that we believe may be beneficial
to you. You may contact us to request that these materials not be sent to
you.
Uses and Disclosures Based On Your Written Authorization:Other uses and
disclosures of your protected health information will be made only with your
authorization,unless otherwise permitted or required by law as described
below.
You may give us written authorization to use your protected 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. Without your written authorization, we will not disclose
your health care information except as described in this notice.
Others Involved in Your Health Care: Unless you object, we may disclose to a
member of your family, a relative, a close friend or any other person you
identify, your protected health information that directly relates 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, general condition
or death.
Marketing: We may use your protected health information to contact you with
information about treatment alternatives that may be of interest to you. We
may disclose your protected health information to a business associate to
assist us in these activities. Unless the information is provided to you by
a general newsletter or in person or is for products or services of nominal
value, you may opt out of receiving further such information by telling us
using the contact information listed at the end of this notice.
Research; Death; Organ Donation: We may use or disclose your protected
health information for research purposes in limited circumstances. We may
disclose the protected health information of a deceased person to a coroner,
protected health examiner, funeral director or organ procurement
organization for certain purposes.
Public Health and Safety: We may disclose your protected health information
to the extent necessary to avert a serious and imminent threat to your
health or safety, or the health or safety of others. We may disclose your
protected health information to a government agency authorized to oversee
the health care system or government programs or its contractors, and to
public health authorities for public health purposes.
Health Oversight: We may disclose protected health information to a health
oversight agency for activities authorized by law, such as audits,
investigations and inspections. Oversight agencies seeking this information
include government agencies that oversee the health care system, government
benefit programs, other government regulatory programs and civil rights
laws.
Abuse or Neglect: We may disclose your protected health information to a
public health authority that is authorized by law to receive reports of
child abuse or neglect. In addition, we may disclose your protected health
information if we believe that you have been a victim of abuse, neglect or
domestic violence to the governmental entity or agency authorized to receive
such information. In this case, the disclosure will be made consistent with
the requirements of applicable federal and state laws.
Food and Drug Administration: We may disclose your protected health
information to a person or company required by the Food and Drug
Administration to report adverse events, product defects or problems,
biologic product deviations; to track products; to enable product recalls;
to make repairs or replacements; or to conduct post marketing surveillance,
as required.
Criminal Activity: Consistent with applicable federal and state laws, we may
disclose your protected health information, if we believe that the use or
disclosure is necessary to prevent or lessen a serious and imminent threat
to the health or safety of a person or the public. We may also disclose
protected health information if it is necessary for law enforcement
authorities to identify or apprehend an individual.
Required by Law: We may use or disclose your protected health information
when we are required to do so by law. For example, we must disclose your
protected health information to the U.S. Department of Health and Human
Services upon request for purposes of determining whether we are in
compliance with federal privacy laws. We may disclose your protected health
information when authorized by workers' compensation or similar laws.
Process and Proceedings: We may disclose your protected health information
in response to a court or administrative order, subpoena, discovery request
or other lawful process,under certain circumstances. Under limited
circumstances,such as a court order, warrant or grand jury subpoena, wemay
disclose your protected health information to law enforcement officials.
Law Enforcement: We may disclose limited information to a law enforcement
official concerning the protected health information of a suspect, fugitive,
material witness, crime victim or missing person. We may disclose the
protected health information of an inmate or other person in lawful custody
to a law enforcement official or correctional institution under certain
circumstances. We may disclose protected health information where necessary
to assist law enforcement officials to capture an individual who has
admitted to participation in a crime or has escaped from lawful custody.
Patient Rights
Access: You have the right to look at or get copies of your protected health
information, with limited exceptions. You must make a request in writing to
the contact person listed herein to obtain access to your protected health
information. You may also request access by sending us a letter to the
address at the end of this notice. If you request copies, we will charge you
$25.00 for each page or$10.00 per hour to locate and copy your protected
health information, and postage if you want the copies mailed to you. If you
prefer, we will prepare a summary or an explanation of your protected health
information for a fee. Contact us using the information listed at the end of
this notice for a full explanation of our fee structure.
Accounting of Disclosures: You have the right to receive a list of instances
in which we or our business associates disclosed your protected health
information for purposes other than treatment, payment, health care
operations and certain other activities after April 14, 2003. After April14,
2009, the accounting will be provided for the past six(6) years. We will
provide you with the date on which we made the disclosure, the name of the
person or entity to whom we disclosed your protected health information, a
description of the protected health information we disclosed, the reason for
the disclosure, and certain other information. If you request this list more
than once in a12-month period, we may charge you a reasonable, cost-based
fee for responding to these additional requests. Contact us using the
information listed at the end of this notice for a full explanation of our
fee structure.
Restriction Requests: You have the right to request that we place additional
restrictions on our use or disclosure of your protected health information.
We are not required to agree to these additional restrictions, but if we do,
wewill abide by our agreement (except in an emergency). Any agreement we may
make to a request for additional restrictions must be in writing signed by a
person authorized to make such an agreement on our behalf. We will not be
bound unless our agreement is so memorialized in writing.
Confidential Communication: You have the right to request that we
communicate with you in confidence about your protected health information
by alternative means or to an alternative location. You must make your
request in writing. We must accommodate your request if it is reasonable,
specifies the alternative means or location,and continues to permit us to
bill and collect payment from you.
Amendment: You have the right to request that we amend your protected health
information. Your request must be in writing, and it must explain why the
information should be amended. We may deny your request if we did not create
the information you want amended or for certain other reasons. If we deny
your request, we will provide you a written explanation. You may respond
with a statement of disagreement to be appended to the information you
wanted amended. If we accept your request to amend the information, we will
make reasonable efforts to inform others, including people or entities you
name, of the amendment and to include the changes in any future disclosures
of that information.
Electronic Notice: If you receive this notice on our website or by
electronic mail (e-mail), you are entitled to receive this notice in written
form. Please contact us using the information listed at the end of this
notice to obtain 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 using the information below. If you believe
that we may have violated your privacy rights, or you disagree with a
decision we made about access to your protected health information or in
response to a request you made, you may complain to us using the contact
information below. 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 protect the privacy of your protected health
information. We will not retaliate in anyway if you choose to file a
complaint with us or with the U.S. Department of Health and Human Services
Name of Contact Person:
Michael P. Banks, DDS
Telephone: 702-477-0844
Address: 811 South Seventh Street
Las Vegas, NV
89101