Joint Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed as well as how you can get access to this information. Please review it carefully.

⇓ Download a Copy of this Notice (.pdf)

OUR OBLIGATIONS

We are required by law to maintain the privacy of your personal health information. We are also required to give you this notice about our privacy practices, our legal obligations, and your rights concerning your health information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect on 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 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 to you when you first receive services from us after the date the revised notice becomes effective or 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 at the end of this notice.

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for our treatment, payment, and health care operations. For example:

Treatment: We may use or disclose your health information to a physician or other health care provider who is providing treatment to you.

Payment: We may use or disclose your health information to your health insurer to obtain payment for services we provide to you.

Health Care Operations: We may use or disclose your health information in connection with our health care operations. Health care operations include quality assessment and improvement activities, reviewing competence or qualifications of health care professionals, evaluating practitioner and provider performance, conducting training programs, accreditation and certification, licensing, or credentialing activities. For example, we may use or disclose your health information in order to conduct an internal assessment of the quality of care that we provide.

Marketing Health –Related Services: We will not use your health information for marketing communications without your written consent.

Your Authorization: Other uses and disclosures of your health information will be made if you give us written authorization to do so. 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.

PATIENT RIGHTS

You have certain rights regarding your health information. These rights include:

1. the right to obtain a paper copy of this notice;
2. the right to inspect and copy your health information (copies are available for a reasonable fee);
3. the right to request amendments to your health information you believe to be accurate;
4. the right to obtain an accounting of North Fulton Smiles' uses and disclosures of your information, subject to certain exceptions;
5. the right to request restrictions on our permitted uses and disclosures of your information (although we are not legally obligated to honor this request); and
6. the right to request that communications regarding your health information be sent by alternative means or at alternative locations.

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 wish to exercise any of your rights described herein, please contact us using the contact information at the end of this notice. You may also 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 upon request. We support your right to the privacy of your health information. We will not retaliate in any way should you choose to file a complaint either with us or the U.S. Department of Health and Human Services.

Contact Officer: Veena Bhat, DDS

Telephone: 770-569-0613

Fax: 770-569-0614

Address: 12315 Crabapple Road, Suite 121, Alpharetta, GA 30004

Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including and identifying or locating) a family member, your personal representative or another person responsible for your care, to the extent necessary to help with your health care or with payment of your health care, if you agree that we may do so. We may also advise these persons 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 and 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 the information that is directly relevant to the person's involvement in your health care. We will also use our professional judgment and our experience with common practice to make reasonable inferences on your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Disclosures Permitted or Required by Law: We are permitted, and in some cases required, by law to make certain other disclosures of health information without your consent. We may disclose your health information, if appropriate, to the following entities under the following circumstances:

1. to public health agencies to satisfy certain reporting requirements, such as births or deaths, certain communicable diseases, child abuse, and other public health issues;
2. to health oversight agencies such as governmental auditors, the Georgia Agency for Health Care Administration, the Georgia Department of Health, and other agencies when required;
3. to any individual when North Fulton Smiles is ordered by a court or other legal process to do so;
4. to law enforcement officials when necessary for law enforcement purposes and as required by law;
5. to a coroner or medical examiner when necessary to enable them to perform their duties;
6. to organ procurement organizations to enable them to make a suitability determination;
7. in cases of emergency;
8. or to researchers if their research has been approved by an institutional review board and they take certain steps to protect your privacy.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters) or information about treatment alternatives or other health-related benefits and services that may be of interest to you.