© 2002 American Dental Association
All Rights Reserved

Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.
This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).

Ridge Dental Care

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 must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 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 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: Filing of insurance claims, communications (written or otherwise) with insurance providers, depositing of payments for services with banking institutions, transfer of records to other physicians you will be seeing for treatment, etc.

Treatment: We may use or disclose your health information to a physician 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. This includes insurance companies, financial and loan institutions such as Care Credit and Dental Fee Plan, and credit card companies and banking institutions.

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.

As part of our general healthcare operations we will also be engaged in the use and disclosure of your health information, unless otherwise notified in writing by you, in the following manner:

· Photos and other renderings including radiographs may be sent to dental labs for the specific purpose of creating dental work for you.

· Your name may be displayed (as a result of your signature) on sign in sheet at the front desk for the purpose of tracking patient arrival and ensuring timeliness of your treatment.

· Your name may be called aloud by one of our staff at time of seating in our operatory(ies) for your dental services.

· As part of our healthcare operations we will display, for the purposes of enlightenment and education to you personally, your radiographs and other vital dental health information on a television type monitor in your treatment room. This would be done usually with the doctor or other health care professional during his/her evaluation of your treatment plan or to answer questions concerning your dental work.

· Your name and other healthcare information may be displayed on a schedule posted in our operatory(ies) which helps us to facilitate and manage our patient care.

· We may, with your consent, take photos and radiographs of your mouth and teeth for treatment and lab purposes and share this information with other health care providers and insurance companies for the express purpose of treatment or payment for services.

· We may obtain financial information from you for the purpose of payment including your credit card information, social security number, date of birth, name and address etc. for the express purpose of bill payment.

· We may, for the purpose of application for credit for services with our practice or to open an account with us for credit extension, perform credit checks with authorized credit bureaus.

· We may exchange information concerning your appointment, scheduled time, payment, services rendered to your spouse or guardian. We may send notices in the mail regarding your appointments or information about your services. We may call to confirm your appointment or to discuss matters concerning your appointment as part of our normal health care operations –with the purpose of ensuring your dental treatment.

· We will send your dental records only by written request from you personally to the address you request. This request must be received in writing prior to records being released.

· We will provide your health care information over the phone only to practitioners, insurance companies, dental labs and members of your family in relation only to your treatment operations and only that information that is needed to render service, treatment or payment or to continue your dental health care, or in the case of an emergency.

· We may discuss financial information with you or make financial arrangements with you at our cashier or check out location or over the phone for the purposes of payment, and if you request we can do this in a private office location.

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 to the extent necessary to help with your healthcare treatment 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.

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

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 official 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).

Patient Rights
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 $2.00 for each page, $26.00 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. Should you request any other information in the form of radiographs ($25.00) or models ($76.00) this will be charged at our normal office fees which includes staff costs for actual duplicate model. 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.

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 may do this but 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.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us at 219-832-1111.

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 Officer: Dr. Andy Koultourides or Privacy Officer

Telephone: 219-832-1111

Fax: 219-836-1410

Address:
Ridge Dental Care,
619 Ridge Road,
Munster, Indiana, 46321