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THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY

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

The following categories describe different ways that we use and disclose your health information without your authorization. For each category we explain and may give an example. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within these categories. We use and disclose health information about you for treatment, payment, and other services.

Treatment:

We may use or disclose your health information to a doctor, nurse, hygienist, technician, receptionist or other healthcare provider who has provided treatment to you, is providing treatment, or we reasonably believe will provide treatment to you. A letter or report will usually be sent to your general dentist, along with other doctors who are related to your care. We may need to talk to another provider who may need to provide care when one of our doctors is away. We may talk with a family member who may assist you with care outside of the office.

Payment:

We may use and disclose your health information to obtain payment for services we provide to you. We may send your health information to an insurance company or other third party. We may tell an insurance company or third party about care you could receive, or are receiving, in order to determine your coverage or obtain prior approval.

Healthcare Operations:

In order to run our practice in a way that ensures that our patients receive quality care, 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. We may include health information in medical reports, and use and disclose health information to contact you by mail, phone, email, sms, or other medium, to remind you of an upcoming visit. We may use and disclose information to leave a voice mail or other message at a phone number you have provided, or to someone who answers a telephone at a number you provided, to provide health information that, in our judgment, needs to be communicated to you. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives or health-related benefits of services that may be of interest to you. We may use health-related information to review our treatment and services and to evaluate the performance of our staff and doctors in caring for you. We may disclose health information to doctors, resident doctors and students for peer review and learning purposes.

Michigan Dental Patient Consent Law:

We are required by Michigan law to obtain your written consent prior to making certain disclosures of your protected health information (PHI).

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 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 federal, state, or local law. For example, we are required to report suspected child or elder abuse, sexually transmitted diseases, etc. We may release health information if asked to do so by a law enforcement official.

Health Oversight Activities:

We may disclose your health information to a health oversight agency for activities authorized by law. These oversight activities may include audits, investigations, inspections, and licensure. These activities are necessary for the government and other agencies to monitor the health care system, benefit programs, and compliance with civil rights laws.

Workers’ Compensation:

We may disclose your health information as authorized by and to the extent necessary to comply with workers’ compensation laws or laws relating to similar programs.

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, 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.

Individuals Involved in Your Care or Payment for Your Care:

We may release health information about you to a friend, a family member or other relative, or any person who is authorized by a parent or guardian to bring a minor patient to our office for care. We may also give information to someone who helps pay for your care.

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 and Pre-Medication Reminders:

We may use or disclose your health information to provide you with appointment and pre-medication reminders (such as voicemail messages, postcards, e-mail, sms, or letters). We may use and disclose your health information to provide appointment reminders by telephone or electronic medium. If you do not wish for us to contact you about treatment alternatives, health-related benefits or appointment reminders, you must notify in writing the person listed on the last page of this notice at each appointment, and state which of those activities you wish to be excluded from.

Other Uses:

If you provide us authorization to use or disclose your health information, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to rake back any disclosures we have already made under the authorization, and that we are required to retain our records of the care that we provide to you.


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, materials, mailing, supplies, 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 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. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.

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 do our best to abide by our agreement (except in an emergency). To request restrictions, you must make your request at each appointment, in writing, to the Privacy Officer named at the bottom of this form. In your request you must tell us 1) what information you want to limit; 2) whether you want to limit our use, disclosure, or both; 3) to whom you want the limits to apply.

Right to Request Confidential or Alternative Communication:

Typically we communicate with you regarding your health care either by the phone numbers you provide, through email, or through mail at your home address. You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. You must make your request in writing, at each appointment, and deliver this request to the office’s Privacy Officer. Your request must specify the alternative means or location. If your requested type of communication increases our costs, there may be a charge to you, which we will do our best to inform you of in advance.

Amendment:

You have the right to request that we amend your health or billing information, as long as that information is kept by our office. Your request must be in writing, delivered to the Privacy Officer at the address listed at the bottom of this form, and it must explain why the information should be amended. We may deny your request under certain circumstances, including but not limited to: if the information was not created by our office, if the person who created the information is no longer available to make an amendment, is not part of the health information kept by our office, is not part of the information which you would be permitted to inspect and copy, or if the information is accurate and/or complete in our judgment.

Right to Restrict Sharing of Patient Health Information:

If you do not want our office to release to your health insurance carriers information regarding your services here or other health information, you should inform our staff. In that case, you will need to pay the charges for your services here yourself, prior to the time that services are provided.

Electronic Notice:

If you receive this Notice on our website or by electronic mail (e-mail) now or in the future, you are entitled to receive this Notice in written form. To obtain a paper copy of this notice, the Privacy Officer listed at the bottom of this form.

Whom This Notice Applies to:

This notice describes the practices of Berkman + Shapiro Orthodontics, PC and those of all officers, employees, staff, or other Covered Entity personnel. These may include all laboratories we utilize for testing of our patients.

Changes to This Notice:

We reserve the right to change this Notice. We reserve the right to make the revised Notice effective for health information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in the waiting room.


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 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 submit a written complaint to us using the contact information listed at the end of this Notice, and/or 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.

Lainie Shapiro, Privacy Officer of Berkman & Shapiro Orthodontics
Telephone: 248-360-7878
Fax: 248-360-7879
Address: 8898 Commerce Road, Suite 5A, Commerce Township, MI, 48382