This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Val Verde Dental is committed to providing high quality health care in a safe and private environment. We are giving you this Notice so you will know about your rights and how we protect your health information.

Our record of your health information
Each time you receive services at Val Verde Dental, a record of your visit is made. This record may describe your condition, diagnoses, treatments and a plan for future care. Medical information such as test results, medications and information obtained by your provider will be recorded.

When we need your written permission to use and disclose your health information
We must obtain your written authorization for uses and disclosures of your health information, except as described below in this Notice.

We may use your health information with Val Verde Dental without your written authorization
We may use your health information without your written authorization for the limited purposes of treatment, payment and health care operations. Examples of such use are as follows:

Treatment – to provide, manage and coordinate care to meet your needs. Your treatment could also involve disclosing information to other providers such as a referring physician or dentist.

Payment – to obtain payment and determine health insurance eligibility. We may tell your health plan about treatment or services that may require their prior approval.

Health Care Operations – to assess the quality of care we provide, to improve our services, to train our staff and students, and to manage our business and services.

Also, unless you object in writing, we may use your health information without your written authorization to:

• Send appointment reminders.
  
• Contact you about patient care issues and treatment choices.
  
• Tell you about services that may interest you or be of benefit to you.
  
• For fundraising.
  

We may be permitted or required to disclose your health information outside Val Verde Dental without your written authorization
We are permitted or required to disclose your health information outside Val Verde Dental without your written authorization for the following purposes:

• To avert serious threat to health or safety to you or to others.
  
• To business associates, who assist us with treatment, payment or health care operations and who must follow our strict privacy rules.
  
• If we are required by law to disclose your health information, such as when we have reason to suspect abuse or neglect of children, elders or disabled persons.
  
• For public health activities to prevent or control disease such as reporting infectious diseases to boards of health, births or deaths or reactions to vaccines or medical devices to the FDA.
  
• For federal and state health oversight activities such as fraud investigations.
  
• As authorized by and necessary to comply with workers’ compensation law if you are injured at work.
  
• For judicial or administrative proceedings in response to a valid court order, summons or subpoena to a hearing, or warrant.
  
• To coroners, medical examiners and funeral directors.
  
• To law enforcement officials for certain potentially criminal activities such as reporting gunshot or stab wounds or to respond to a warrant.
  
• For specialized government functions such as national security or intelligence inquiries.
  
• To a correctional institution if you are an inmate.
  
• For research preparation and research under strict privacy procedures to protect your information.
  
• Unless you tell us otherwise, to family and friends involved in your care if, in our professional judgment, the disclosure is in your interests.
  
• Unless you tell us otherwise, to persons who inquire about you specifically by name, limited information about your condition and that your are being seen at Val Verde Dental.
  

We are also subject to state and federal laws that give special protection to certain types of health information, and we will be careful to comply with these laws if applicable. These laws relate to:

• HIV testing or test results.
  
• Genetic testing and test results.
  
• Substance abuse and rehabilitation treatment information.
  
• Sensitive information such as sexual assault counseling records or communications between you and a social worker, psychologist, psychotherapist or licensed mental health nurse clinical specialist.
  
• Psychotherapy notes (notes maintained outside of the medical record for the therapist’s own use). However, specific permission is not required for use or sharing of these notes if used by your therapist to treat you, for training programs, for legal defense in an action you bring, or for professional oversight of the therapist.
  
  

Your rights regarding your health information
You have the following rights with respect to your health information. You have the right to:

• Request, in writing, that we limit how we use or disclose your health information, but we may not be able to comply with all requests.
  
• Revoke, in writing, any authorization you have given to disclose your information; but, we won’t be able to take back information we have already disclosed.
  
• Inspect and receive copies of your medical information for a fee. This may not include psychotherapy notes, clinical laboratory data or information compiled in anticipation of or use in a civil, criminal or administrative action or proceeding. This right may also be suspended temporarily for information created during research until the research is finished.
  
• Request how we communicate with you, and we will try to accommodate reasonable requests.
  
• Request in writing additions or corrections to your health information. We may not agree to your request if we did not create the information, if the information is not kept by us to make decisions about you, if the information is not part of what you are allowed to inspect or copy, or if the information is complete and correct.
  
• Request in writing and receive an accounting of the disclosures we have made of your health information, except for disclosures for treatment, payment, health care operations, disclosures you authorize, and some required disclosures.
• Obtain a paper copy of this Notice even if you receive it electronically.

Our responsibilities
We are required by law to:

• Maintain privacy of your information.
  
• Provide this Notice of our duties, your rights and our privacy practices.
  
• Abide by the terms of our Notice as currently in effect.
  
• Notify you if we are unable to continue to comply with your restriction request.
  
• We reserve the right to change our privacy practices, and this Notice and to make the new practices effective for all your information including information we already have about you. Revised Notices will be posted at our treatment site.
  

To exercise your rights or file a complaint
If you have questions about this Notice, would like to exercise your rights, or wish to file a formal complaint regarding privacy of your health information, you may contact the Records Administrator at the Val Verde Dental Office at:

All complaints will be investigated and you will not be penalized or subject to retaliation for filing a complaint.

In addition to contacting the Records Administrator listed above, you may also file a complaint with the federal government. Contact:

Secretary of Health and Human Services
200 Independence Ave. SW
Washington, D.C., 20201

Ref: Val Verde Dental Privacy Notice [F] 4/14/03