Gregory K. Fong, D.D.S., Inc.

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
State and Federal laws require us to maintain the privacy of your health information and to inform you about our privacy practices by providing you with this notice.  We must follow the privacy practices as described below.  This Notice will take effect onApril 14, 2003 and will remain in effect until it is amended or replaced by us.

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 your health information to provide you with our professional services.  This information is necessary for your dentist to determine what treatment you should receive.  Information obtained by your dentist will be included in your dental records that is related to your treatment.  We may also disclose your health information to a physician or other healthcare provider providing treatment to you, including but not limited to dental laboratories.

Payment:  We may use and disclose your health information to obtain payment for services we provide to you.  This may include insurance carriers and other businesses that may become involved in the collection of unpaid balances.

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.

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, including an interpreter or caregiver, 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.

Required by Law:  We may use or disclose your health information when we are required to do so by law.   (Examples: Court or administrative orders, subpoena, discovery request or other lawful process.) We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

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. 

Public Health:  Your health information may be used or disclosed for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury or disability, or for other health oversight activities.

Decedents:  Health information may be disclosed to funeral directors or coroners to enable them to carry out their lawful duties. 

Workers Compensation:  Your health information by be used or disclosed in order to comply with laws and regulations related to Workers Compensation.

Appointment Reminders:  We may use or disclose your health information to provide you with appointment reminders, including, but not limited to, email, text, voicemail messages, postcards or letters.


 

YOUR PRIVACY RIGHTS AS OUR PATIENT:                                                                                                                                                                                                                                                                                                                                                                                            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 must make a request in writing to obtain access to your health information.)  You may obtain a form to request access by using the contact information listed at the end of this Notice.  We will charge you a reasonable cost-based fee for expenses such as copies and staff time.  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 $0.50 for each page, $2.00 for each  x-ray and $25.00 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you.  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, but not before April 14, 2003.  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 required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). 

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 Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.


 

OBLIGATIONS AS YOUR DENTIST: As your dentist,we are required to:

  • Maintain the privacy of your protected health information
  • Provide you with this notice of its legal duties and privacy practices with respect to your health information.
  • Abide by the terms of this notice.
  • Notify you if we are unable to agree to a requested restriction on how your information if used and disclosed.
  • Accommodate reasonable requests you may make to communicate health information by alternative means or at alternative locations.
  • Obtain your written authorization to use or disclose your health information for reasons other than those listed above and permitted under law.

We  reserve the right to change our privacy practices and to make new provisions effective for all protected health information we maintain.  As notices are revised, copies will be made available.


 

QUESTIONS AND COMPLAINTS:

If you want more information about our privacy practices or have questions or concerns, please contact us.

If 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, your insurance carrier, or with the U.S. Department of Health and Human Services if you believe your privacy rights have been violated.

Contact Officer:   Janet Fong

Telephone:          (808) 596-8218

Mailing Address:  Gregory K. Fong, D.D.S.

                           Attention: Janet Fong/HIPAA Privacy Officer

                           1221 Kapiolani Blvd., Suite 240

                           Honolulu,  HI 96814

 

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