HIPAA 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.
PURPOSE: This Notice of Privacy Practices (“Notice”), presents the information that federal law requires us to give our patients regarding our privacy practices. This Notice reflects our dental practice’s particular privacy policies and Georgia’s state laws. For purposes of this Notice “We”, “Practice” or similar language refers to Melody Schiffer, D.M.D., P.C., d/b/a Gwinnett Dental Implant and Periodontal Center.
We must provide this Notice to each patient beginning no later than the date of our first service delivery to the patient, including service delivered electronically, after April 14, 2003. We must make a good-faith attempt to obtain written acknowledgement of receipt of the Notice from the patient. We must also have the Notice available at the office for patients to request to take with them. We must post the Notice in our office in a clear and prominent location where it is reasonable to expect any patients seeking service from us to be able to read the Notice. Whenever the Notice is revised, we must make the Notice available upon request on or after the effective date of the revision in a manner consistent with the above instructions. Thereafter, we must distribute the Notice to each new patient at the time of service delivery and to any person requesting a Notice. We must also post the revised Notice in our office as discussed above.
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 are required to notify you of a breach of your health information. We must follow the privacy practices that are described in this Notice while it is in effect. The original Notice was effective February 3, 2003, and was amended effective August 18, 2017.
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.
USES AND DISCLOSURES OF HEALTH INFORMATION: We use and disclose health information about you for treatment, payment, and healthcare operations. For example:
Treatment: We may use or disclose your health information to a dentist or other healthcare provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
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 or otherwise as permitted or required by law.
To Your Family and Friends: 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.
Persons Involved in Care: 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.
Authorization Required: We will not use your health information for the following without your authorization: (1) for marketing purposes unrelated to our services; (2) for fundraising; (3) sale of your health information; or (4) release of psychotherapy records (typically, we do not maintain such records).
Required by Law: We may use or disclose your health information when we are required to do so by law.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement officials having lawful custody of protected health information of inmate or patient under certain circumstances.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).
Sign in sheet: We may use a daily sign in sheet. Your name may be seen by other patients signing this sheet at a later time.
Business Associates: At times, we use subcontractors to perform services on our behalf, who may create, maintain, receive, or transmit health information on our behalf, which may involve your health information. We obtain reasonable assurances from our business associates that they will safeguard your health information to the same extent we are required to by law.
Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You may obtain a form to request access by using the contact information listed at the end of this Notice. We may charge you a reasonable fee of up to $20.00 for search, retrieval, and other direct administrative costs (e.g., staff time) to complete your request for copies of your health information. A fee for certifying the dental records may also be charged not to exceed $7.50 for each record certified. The actual cost of postage incurred in mailing the requested health information may also be charged if you request documents to be mailed to you. In addition, copying costs for your health information shall not exceed $.75 per page for the first 20 pages of the patient’s records which are copied; $.65 per page for pages 21 through 100; and $.50 for each page copied in excess of 100 pages. You may also request access by sending us a letter to the address at the end of this Notice. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your 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.
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.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not generally required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). We are required to abide by a request to restrict disclosure of your health information to a health plan if you (or someone on your behalf other than the health plan) paid in full for the services for which the information is requested, the disclosure is for purposes of payment or healthcare operations, and we are not otherwise required by law or regulation to make the disclosure.
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.
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.
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 our Privacy Officer: Sheila Curry
Gwinnett Dental Implant and Periodontal Center
320 Killian Hill Road, NW
Lilburn, GA 30047
Telephone (770) 921-3555
Fax (770) 564-2244
ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
Notice to Patient:
I have read and understand the following statements of my rights:
• This authorization will remain in effect for the earlier of one (1) year or until I revoke it in writing. I understand that I may revoke this authorization at any time by providing written notice to: Melody Schiffer, D.M.D., P.C., Attn: Privacy Officer, 320 Killian Hill Road, NW, Lilburn, Georgia 30047; e-mail: email@example.com. However, the revocation will not have any effect on any actions taken before its receipt and processing.
• I may see and copy the information described on this form, if requested.
• I am not required to sign this form to receive treatment, health care benefits, and my refusal to sign this Authorization will not affect my treatment, payment, enrollment, or eligibility for benefits or the quality of care that I will receive.
• I received the Notice of Privacy Practices and had the opportunity to ask questions about it, as well as about the use and disclosure of my PHI before signing. The Notice of Privacy Practices is subject to change at any time.
• I understand that information released pursuant to this authorization may no longer be protected by state law or the federal health privacy law and could be re-disclosed by the person or entity that receives it.
• I am aware that per O.C.G.A. § 31-33-3, as may be amended from time-to-time, a charge of up to $20.00 may be collected for search, retrieval, and other direct administrative costs related to compliance with the request under this chapter. A fee for certifying the medical records may also be charged not to exceed $7.50 for each record certified. The actual cost of postage incurred in mailing the requested records may also be charged. In addition, copying costs for a record which is in paper form shall not exceed $.75 per page for the first 20 pages of the patient’s records which are copied; $.65 per page for pages 21 through 100; and $.50 for each page copied in excess of 100 pages.
• A copy of this authorization is as valid as the original and is subject to its terms and conditions.
Authorization and Signature
I hereby authorize the use of disclosure of my individually identifiable PHI as described herein. I understand that this Authorization is voluntary. I understand that treatment, payment, enrollment or eligibility of benefits may not be conditioned on my signing this Authorization. I
further understand that if the organization authorized to receive the information is not a health plan or health care provider, the released information could potentially be re-disclosed and may no longer be protected by federal privacy regulations. Therefore, I release Melody Schiffer, D.M.D., P.C. from all liability arising from this disclosure of my health information.
I understand and agree that I am financially responsible for the following fees associated with my request: a charge of up to $20.00 may be collected for search, retrieval, and other direct administrative costs related to compliance with the request under this chapter. A fee for certifying the medical records may also be charged not to exceed $7.50 for each record certified. The actual cost of postage incurred in mailing the requested records may also be charged. In addition, copying costs for a record which is in paper form shall not exceed $.75 per page for the first 20 pages of the patient’s records which are copied; $.65 per page for pages 21 through 100; and $.50 for each page copied in excess of 100 pages in accordance with O.C.G.A. § 31-33-3, as may be amended from time-to-time.
The Practice is required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign this form to acknowledge receipt of the Notice. You may refuse to sign this acknowledgement, if you wish.
Our Dental Service Area
We’re located in Lilburn, but we have happy patients that ask for a holistic dentist. Many patients come to us from all around the Lilburn area such as Snellville, Lawrenceville, Suwanee, Duluth, Norcross, and Stone Mountain. Call us and let us take care of you.
We always welcome and appreciate referrals from our patients.
Gwinnett Dental Implant Center
320 Killian Hill Rd NW
Lilburn, GA 30047
Phone: (770) 921-3555