July 28, 2020
Uses & Disclosures
There are a number of situations where Des Moines Cosmetic Dentistry Center and Stephen Forrest, DDS may use or disclose to other persons or entities your confidential medical information. Certain uses and disclosures will require your consent, such as those related to treatment, payment, or health care operations. Other disclosures will require specific authorization from you, and certain disclosures required by law or under emergency circumstances may be made without your consent. Under any circumstance, we will use or disclose only the minimum amount of information necessary from your medical records to accomplish the intended purpose of the disclosure.
Use & Disclosure with Patient Consent
We will obtain your general consent to use and disclose your confidential medical information for the following purposes:
We will use your medical information to make decisions about the provision, coordination, or management of your health care, including diagnosing your condition and determining the appropriate treatment for that condition. It may also be necessary to share your medical information with another health care provider whom we need to consult with respect to your care. We may also disclose certain information to a pharmacist for the purpose of filling a prescription for you, or to a facility or other providers should you require surgery or other hospital care. These are only examples of uses and disclosures of medical information for treatment purposes which may or may not be necessary in your case.
We may need to use or disclose information in your medical record to obtain reimbursement from you or your health insurance plan or another insurer for our services rendered to you. This may also include determinations of eligibility or coverage under the appropriate health plan, pre-certification, and pre-authorization of services, or review of services for purposes of reimbursement. This information may also be used for billing, claims management, and collection purposes together with related health care data processing through our system.
Your medical records may be used in our business planning and development operations, including improvement in our methods of operation, and general administrative functions. We may also use the information in our overall compliance planning, medical review activities, and arranging for legal and auditing functions.
Use & Disclosure Without Consent
There are certain circumstances under which we may use or disclose your medical information without first obtaining your consent or authorization. Those circumstances generally involve public health and oversight activities, law enforcement activities, judicial and administrative proceedings, and in the event of death. Specifically, we are required to report information concerning certain communicable diseases, sexually transmitted diseases, and HIV/AIDS status. We are also required to report instances of suspected or documented abuse, neglect, or domestic violence. Furthermore, we are required to report to appropriate agencies and law enforcement officials information that you or another person are in immediate threat or danger to your health or safety as a result of violent activity. We must also provide medical record information when ordered by a court of law to do so.
Authorization for Use or Disclosure
Except as outlined in the above section, your medical information will not be used or disclosed to any other person or entity without your specific authorization, which may be revoked at any time. In particular, except to the extent disclosure has been made to governmental entities required by law to maintain the confidentiality of the information, information will not be further disclosed to any other person or entity with respect to mental health treatment, drug and alcohol abuse, HIV/AIDS, or sexually transmitted diseases information which may be contained in your medical records. We likewise will not disclose your medical record information to an employer for purposes of making employment decisions, to a liability insurer or attorney as a result of injuries sustained in an automobile accident, or to educational authorities, without your written authorization.
Additional Uses & Disclosures
We may contact you from time to time to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
You have certain rights with respect to your medical record information, as follows:
- You may request that we restrict the uses and disclosures of your medical records information for treatment, payment and operations, or restrictions involving your care or payment related to that care. We are not required to agree with restriction; however, if we agree, we will comply with it, except with respect to emergencies, disclosure of the information to you, or if we are otherwise required by law to make a full disclosure without restriction.
- You have the right to request a receipt of confidential communications of your medical information by an alternative means or at an alternative location. If you require such accommodation, you will be charged a fee for the accommodation and will be required to specify the alternative address or method of contact and how payment will be handled.
- You have the right to inspect, copy and request an amendment to your medical records. Access to your medical records will not include psychotherapy notes contained in them or information compiled in anticipation of or for use in a civil, criminal, or administrative action or proceeding or for which your access is otherwise restricted by law. We will charge a reasonable fee for providing a copy of your medical records, or a summary of those records, at your request, which includes the cost of copying, postage, or preparation of an explanation or summary of the information.
- All requests for inspection, copying and/or amending information in your medical records must be made in writing and be addressed to “Privacy Officer” at Des Moines Cosmetic Dentistry Center and Stephen Forrest, DDS’s address. We will respond to your request in a timely fashion.
- You have the right to receive an accounting of all disclosures we make to other persons or entities of your medical records information except for disclosures required for treatment, payment, and health care operations, or otherwise required by law as specified above. We will charge a reasonable fee for each accounting.
- You have the right to obtain a paper copy of this notice.
- All requests related to your rights herein must be made in writing and addressed to the Privacy Officer at the address below.
Des Moines Cosmetic Dentistry Center and Stephen Forrest, DDS Duties
Des Moines Cosmetic Dentistry Center and Stephen Forrest, DDS has the following duties with respect to the maintenance, use, and disclosure of your medical records:
- Des Moines Cosmetic Dentistry Center and Stephen Forrest, DDS is required by law to maintain the privacy of the protected health information in your medical records and to provide you with this Notice of its legal duties and privacy practices with respect to that information.
- Des Moines Cosmetic Dentistry Center and Stephen Forrest, DDS is required to abide by the terms of this Notice currently in effect.
- Des Moines Cosmetic Dentistry Center and Stephen Forrest, DDS reserves the right to change the terms of this Notice at any time, thereby making the new provisions effective for all health information and medical records it has and continues to maintain. All changes in this Notice will be prominently displayed and available at the reception desk.
You may file a written complaint to Des Moines Cosmetic Dentistry Center and Stephen Forrest, DDS or to the Secretary of Health and Human Services if you believe your privacy rights with respect to confidential information in your medical records have been violated. All complaints must be in writing and must be addressed to the Privacy Officer or to the person designated by the U.S. Department of Health and Human Services if Des Moines Cosmetic Dentistry Center and Stephen Forrest, DDS cannot resolve your concerns. You will not be retaliated against for filing such a complaint.
Contact Person: All questions concerning this Notice or requests made pursuant to it should be addressed to: Des Moines Cosmetic Dentistry Center and Stephen Forrest, DDS, 2375 Berkshire Pkwy, Clive, IA 50325. Phone: (515) 516-6769. Email: email@example.com.