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

 

Your protected health information (i.e. individually identifiable information such as names, dates, phone/fax numbers, email addresses, home address, social security numbers, and demographic data) may be used or disclosed by us in one or more of the following respects:

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• To other health care providers (e.g. your general dentist, oral surgeon, etc.) in connection with our rendering orthodontic treatment to you (e.g. to determine the results of cleanings, surgery, etc.);
   

• To third party payors or spouses (e.g. insurance companies, employers with direct reimbursement, collections agencies, administrators of flexible spending accounts, etc.) in order to obtain payment of your account (e.g. to determine, collect or disburse financial obligations, benefits, dates of payment, etc.);
   

• To certifying, licensing and accrediting bodies (e.g. the American Board of Orthodontics, state dental boards, etc.) in connection with obtaining certification, licensure or accreditation;
   

• Internally, to staff members who have any role in your treatment;
   

• To other patients and third parties who may see or overhear incidental disclosures about your treatment, scheduling, etc;
   

• To your family and close friends involved in your treatment; and/or
   

• We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

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Any other uses or disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke. 

 

Under the new privacy rules, you have the right to:

• Request restrictions on the use and disclosure of your protected health information.

• Request confidential communication of your protected health information.

• Inspect and obtain copies of your protected health information through asking us.

• Amend or modify your protected health information in certain circumstances

• Receive an accounting of certain disclosures made by us of your protected health information
  
   

You may, without risk of retaliation, file a complaint as to any violation by us of your privacy rights with us (by submitting inquiries to our privacy contact person at our office address) or the United States Secretary of Health and Human Services (which must be filed within 180 days of the violation).

 

We have the following duties under the privacy rule:

 

By law, to maintain the privacy of protected health information and to provide you with this notice setting forth our legal duties and privacy practices with respect to such information:

• To abide by the terms of our Privacy Notice and to make the new notice provisions effective for all protected health information by us, and that if we do so, a copy will be sent upon request.

• We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will post the revised information on our website and in our office. A copy of the changes will be available upon request.

Please note that we are not obligated to:

• Honor any request by you to restrict the use or disclosure of your protected health information;

• Amend your protected health information if, for example, it is accurate and complete; or,

• Provide an atmosphere that is totally free of the possibility that your protected health information may incidentally be overheard by other patients and third parties.
   

This privacy notice is effective as of March 1, 2017. We will attempt to obtain written acknowledgment of receipt of our Privacy Notice. If you have any questions about the information in the Notice, please ask for our Privacy Contact Person or direct your questions to this person at our office address:

 

Ortho Smiles

1510 Doctors Court

Watertown, WI 53094

Phone: (262) 222-1111

 

Please sign and return the Acknowledgment form. If we have treated any other members of your family which are under the age of eighteen (18), please list their names on the acknowledgment form as well. 

 

Thank you,

 

Ortho Smiles