REQUEST AN APPOINTMENT HOME CAREERS LOCATIONS CONTACT US NOTICE OF PRIVACY PRACTICES Revision Date: 3/26/2013 THIS NOTICE DESCRIBES HOW DENTAL OR MEDICAL INFORMATION ABOUT YOU MAY BE USED AND/OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Ocean Dental and all of its affiliated entities are committed to protecting your dental or medical information. We are required by law to: – Maintain the privacy of your dental or medical information; – Give you a notice of our legal duties and privacy practices with respect to your dental or medical information; and – Follow the terms of the notice currently in effect. What is this document? This Notice of Privacy Practices describes how we may use and/or disclose your dental or medical information. It also describes your rights to access and control your dental or medical information. What does this Notice cover? This Notice of Privacy Practices applies to all of your dental or medical information used to make decisions about your care that we generate or maintain, including sensitive information such as mental health, communicable disease and drug and alcohol abuse information. Different privacy practices may apply to your dental or medical information that is created or kept by other people or entities. Who does this Notice cover? This Notice of Privacy Practices will be followed by aII Ocean Dental employees and any health care professional who provides treatment to you on behalf of Ocean Dental. What will you do with my dental or medical information? The following categories describe the ways that we may use and/or disclose dental or medical information. Not every use and/or disclosure in a category will be listed. You will acknowledge receipt of this document by signing the accompanying Patient Agreement and Acknowledgement. If you are concerned about a possible use and/or disclosure of any part of your dental or medical information, you may request a restriction in writing. Your right to request a restriction is described in the section regarding patient rights below. Treatment. We will use your dental or medical information to provide you with dental or medical treatment and services. Example: Your dental or medical information may be disclosed to dentists, nurses, hygienists, technicians, students, or other personnel who are involved in taking care of you. We may disclose your dental or medical information for the treatment activities of any other health care providers. Example: We may send a copy of your dental or medical record to a dentist, physician, oral surgeon, orthodontist, dental or medical professional, hospital or surgery center who needs to provide follow-up care. Payment. We may use dental or medical information about you for our payment activities. Common payment activities include, but are not limited to: – Determining eligibility or coverage under a plan; and – Billing and collection activities. Examples: (1) Your dental or medical information may be disclosed to an insurance company to obtain payment for services. (2) We may tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. We may disclose dental or medical information about you to another health care provider or covered entity for its payment activities. Example: We may send your health plan coverage information to an outside laboratory that needs the information to bill for tests that it provided to you. Operations. We may use your dental or medical information for operational or administrative purposes. These uses are necessary to run our dental practice and to make sure patients receive quality care. Common operation activities include, but are not limited to: – Conducting quality assessment and improvement activities; – Reviewing the competence of health care professionals; – Arranging for legal or auditing services; – Business planning and development; – Business management and administrative activities; and – Communicating with patients about our services. Examples: (1) We may use your dental or medical information to conduct internal audits to verify that billing is being conducted properly. (2) We may use your dental or medical information to contact you for the purposes of conducting patient satisfaction surveys or to follow-up on the services we provided. (3) We might use a patient list to announce the arrival of a new dentist or the purchase of a new piece of equipment or the addition of a new service. We may disclose dental or medical information about you to another health care provider or covered entity for its operation activities under certain circumstances. Example: We may disclose your dental or medical information to your health plan for its utilization review analysis. Business Associates. We may disclose your dental or medical information to other entities that provide a service to us or on our behalf that requires the disclosure of patient dental or medical information. However, we will only make these disclosures if we have received satisfactory assurance that the other entity will properly safeguard your dental or medical information. Example: We may contract with another entity to provide transcription or billing services. Treatment Alternatives. We may use and/or disclose your dental or medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. Individuals Involved in Your Care or Payment for Your Care. We may disclose dental or medical information about you to a friend, family member or legal guardian who is involved in your dental or medical care. Appointment Reminders. We may use and/or disclose dental or medical information to contact you as a reminder that you have an appointment for dental or medical treatment or services. Health-Related Benefits and Services. We may use and/or disclose dental or medical information to tell you about health-related benefits or services that may be of interest to you. Research. We may use and/or disclose dental or medical information about you to researchers. In most circumstances, you must sign a separate form specifically authorizing us to use and/or disclose your dental or medical information for research. However, there are certain exceptions. Your dental or medical information may be disclosed without your authorization for research if the authorization requirement has been waived or altered by a special committee that is charged with ensuring that the disclosure will not pose a great risk to your privacy or that measures are being taken to protect your dental or medical information. Your dental or medical information also may be disclosed to researchers to prepare for research as long as certain conditions are met. Dental or medical information regarding people who have died can be disclosed without authorization under certain circumstances. Limited dental or medical information may be disclosed to a researcher who has signed an agreement promising to protect the information disclosed. Organ and Tissue Donation. If you are an organ donor, we may disclose dental or medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation. Can you ever use and/or disclose my dental or medical information without my authorization? Yes. The following categories describe the ways that we may be required to use and/or disclose your dental or medical information without your consent. Not every use and/or disclosure in a category will be listed. Required by Law. We may disclose your dental or medical information when required to do so by federal, state or local law. Examples: (1) We may disclose your dental or medical information for workers’ compensation or similar programs. These programs pro-vide benefits for work-related injuries or illness. (2) We are required by law to report cases of suspected abuse and neglect. These reports may include your dental or medical information. Public Safety. We may use and/or disclose dental or medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure would only be to someone able to help prevent the threat. Public Health. We may disclose dental or medical information about your public health activities intended to: – Prevent or control disease, injury or disability; – Report births and deaths; – Report abuse, neglect or violence as required by law; – Report reactions to medications or problems with products; – Notify people of recalls of products they may be using; or – Notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. Example: State law may require us to report, among other things, tumors, birth defects, cases of venereal disease, infant eye infections, infants born exposed to alcohol and other harmful substances, and abortions. Food and Drug Administration (FDA). We may disclose to the FDA and to manufacturers health information relative to adverse events with respect to food, supplements, product and product defects, or post-marketing surveillance information to enable product recalls, repairs or replacements. Health Oversight Activities. We may disclose dental or medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws. Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose dental or medical information about you in response to a court or administrative order. In limited circumstances, we may disclose dental or medical information about you in response to a subpoena or discovery request. Law Enforcement. We may disclose dental or medical information if asked to do so by law enforcement officials: – In response to a court order, warrant, summons or other similar process; – To identify or locate a suspect, fugitive, material witness, or missing person; – About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; – About a death we believe may be the result of criminal conduct; – About criminal conduct at one of our clinics; and – In emergency circumstances to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime. Coroners, Medical Examiners and Funeral Directors. We may disclose dental or medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. National Security and Intelligence Activities. We may disclose dental or medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. Protective Services for the President and Others. We may disclose dental or medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations. Military/Veterans. We may disclose your dental or medical information as required by military command authorities, if you are a member of the armed forces. Inmates. If you are an inmate of a correctional facility or under the custody of a law enforcement official or agency, we may disclose your dental or medical information to the correctional facility or law enforcement official or agency. This disclosure may be necessary to: (1) enable the correctional facility to provide you with health care; or (2) protect the health and safety of you and/or other people. Fundraising Communications. We may use or disclose to a business associate or to an institutionally related foundation, the following protected health information for the purposes of raising funds, without your authorization. The information to be disclosed would be demographic information such as your name, address, contact information, age, gender, date of birth, dates when health care service was provided, department of service, treating dentist or physician, outcome information, and health insurance status. What uses and/or disclosures of my dental or medical information would require my authorization? Psychotherapy notes, protected health information for marketing purposes, and the sale of protected health information require a separate, specific authorization from you to use or disclose your dental or medical information. What if you want to use and/or disclose my dental or medical information for a purpose not described in this Notice? We must obtain a separate, specific authorization from you to use and/or disclose your dental or medical information for any purpose not covered by this notice or the laws that apply to us. If you provide us with authorization to use and/or disclose your dental or medical information, you may revoke the authorization, in writing, at any time. If you revoke your authorization, we will not use and/or disclose your dental or medical information for the reasons covered by your authorization. However, your revocation will not apply to disclosures already made by us in reliance on your authorization. What are my rights regarding my dental or medical information? You have the rights described below in regard to the dental or medical information that we maintain about you. You are required to submit a written request to exercise any of these rights. You may contact our Clinic or Practice Manager or Privacy Officer to obtain a form that you can use to exercise any of the rights listed below. Right to Inspect and Copy. You have the right to inspect and/or copy dental or medical information used to make decisions about your care. If you want a copy of your dental or medical information, we may charge a fee of $1.00 for the first page and .50 cents for each subsequent page. We may deny your request to inspect and/or copy your dental or medical information in certain circumstances. If you are denied access, you may request that the denial be reviewed. A licensed health care professional chosen by us will review your request and the denial. The person conducting the review will not be the person who denied your original request. We will comply with the outcome of the review. Right to Amend. If you feel the dental or medical information that we created is incorrect or incomplete, you may submit a written request for an amendment for as long as we maintain the information. You must provide a reason that supports your amendment request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask to amend information that: – We did not create, unless the person or entity that created the information is not available to make the amendment; – Is not part of the dental or medical information that we maintain; – Is not part of the information that you would be permitted to inspect and/or copy; or – Is accurate and complete. Right to an Accounting of Disclosures. You have the right to request one free “accounting of disclosures” every 12 months. This is a list of certain disclosures we made of your dental or medical information. There are several categories of disclosures that we are not required to list in the accounting. For example, we do not have to keep track of disclosures that are authorized. Your request must state a time period, which may not be longer than 6 years and may not include dates before April 14, 2003. If you request more than one accounting in a 12-month period, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. Right to Request Restrictions. You have the right to request a restriction or limitation on the dental or medical information we use and/or disclose about you unless our use and/or disclosure is required by law. You also have the right to request a limit on the dental or medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. We are required to agree to your request to put restrictions on the disclosure of information to your health plan, if the disclosure is for the purposes of carrying out payment or health care operations and is not otherwise required by law; and the protected health information pertains solely to a health care item or service and you are willing, or another person on behalf of you, is willing to pay out of pocket for the dental or medical treatment provided. We will comply with your request, unless the information is needed to provide emergency treatment to you. In your request, you must indicate: – The type of restriction you want and the information you want restricted; and – To whom you want the limits to apply, for example, your spouse. Right to Request Confidential Communications. You have the right to request that we communicate with you about dental or medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. Right to Receive Breach Notification. You have the right to and will receive information of any breach of your protected health information. Right to a Paper Copy of This Notice. You have the right to a paper copy of this notice. Copies of this notice will always be available at our office. Can you change this notice? We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for dental or medical information we already have about you as well as any information we receive in the future. Copies of the current notice will be posted at each of our clinics and will be available for you to pick up on each visit to our office. What if I have questions or need to report a problem? If you believe your privacy rights have been violated, you may file a complaint with us or with the Office of Civil Rights of the Department of Health and Human Services. To file a complaint with us or if you would like more information about our privacy practices, contact our Privacy Officer at 1-855-437-0332 or by email at Compliance@oceandental.net. The Privacy Officer’s mailing address is 206 West 6th Avenue, Stillwater, Oklahoma 74074. To file a complaint with the Office of Civil Rights of the Department of Health and Human Services, you must submit the complaint within 180 days of when you knew or should have known of the circumstance that led to the complaint. The complaint must be submitted in writing. Information on how to file a complaint can be located on the Office of Civil Rights website at: http://www.hhs.gov/ocr/privacy/index.html or our Privacy Officer can provide you with current contact information. You will not be penalized for filing a complaint. Ocean Dental will comply with all state and federal HIPAA regulations. Home Office 209 Lilac Dr Suite 120 Edmond, OK 73034 (405)707-0600 (405)707-0602 info@oceandental.net Our Services OUR VISION & VALUES ABOUT US PRIVACY POLICY NOTICE OF PRIVACY PRACTICES NOTICE OF NONDISCRIMINATION TERMS OF USE Our Staff Dentist Dental Assistant Clinical Coordinator Practice Manager Office Assistant Hygienist © Copyright Ocean Dental 2018. All rights reserved.