River Valley Oral and Maxillofacial Surgery, Ltd.
RVOMS
930 16th AVE
Moline, IL 61265
(309) 797-1770
Business Office (309) 797-5633
Fax (309)797-1791
NOTICE OF
PRIVACY PRACTICES
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.
The health Insurance Portability
& Accountability Act of 1996 ("HIPAA") is a federal program that
requires that all medical records and other individually identifiable health
information used or disclosed by us in any form, whether electronically, on
paper, or orally, are kept properly confidential. This Act gives you, the
patient, significant new rights to understand and control how your health
information is used. HIPAA provides penalties for covered entities that misuse
personal health information.
As required by
HIPAA, we have prepared this explanation of how we are required to maintain the
privacy of your health information and how we may use and disclose your health
information.
If you sign a
Consent Form, we may use and disclose your medical records only for each of the
following purposes: treatment, payment and health care operations.
•
Treatment means providing, coordination, or managing health care and related
services by one or more health care providers. Examples of this would be
surgery, consultations, and referrals to other healthcare providers.
•
Payment means such activities as obtaining reimbursement for services,
confirming coverage, billing or collection activities, and
utilization review. An example of this would be sending a bill for your visit
to your insurance company for payment.
•
Health care operations include the business aspects of running our practice,
such as conducting quality assessment, auditing, credentialing, cost-management
analysis, and customer service. An example would be a review of patient charts
that underwent a specific procedure for quality control.
We may also
create and distribute de-identified health information by removing all
references to individually identifiable information.
We may, without
prior consent, use, or disclose protected health information to carry out
treatment, payment, or health care operations in the following circumstances:
• In emergency treatment situations, if we attempt
to obtain such consent as soon as reasonably practicable after the delivery of
such treatment;
• If we are required by law to treat you, and we
attempt to obtain such consent but are unable to obtain such consent; or
• If we attempt to obtain your consent but are
unable to do so due to substantial barriers to communicating with you, and we
determine that, in our professional judgment, your consent to receive treatment
is clearly inferred from the circumstances.
We may contact you over the phone to provide
appointment reminders, postoperative status, or information about treatment
alternatives or other health-related benefits and services that may be of
interest to you.
As
a multiple doctor practice, it may be necessary to share your personal health
information between doctors to facilitate your treatment and follow up care.
Any
other uses and disclosures will be made only with your written authorization.
You may revoke such authorization in writing and we are required to honor and
abide by that written request, except to the extent that we have already taken
actions relying on your authorization.
You
have the following rights with respect to your protected health information,
which you can exercise by presenting a written request to the Privacy Officer:
• The right to request restrictions on certain
uses and disclosures of protected health information, including those related
to disclosures to family members, other relatives, close personal friends, or
any other person identified by you. We are, however, not required to agree to a
requested restriction. If we do agree to a restriction, we must abide by it
unless you agree in writing to remove it.
• The right to reasonable requests to receive confidential
communications of protected health information from us by alternative means or
at alternative locations.
• The right to inspect and copy your protected
health information.
• The right to amend your protected health
information.
• The right to receive an accounting of
disclosures of protected health information.
• The right to obtain a paper copy of this notice
from us upon request.
We are required by law to maintain the privacy of your protected
health information and to provide you with notice of our legal duties and
privacy practices with respect to protected health information.
We will, from
time to time, have students of Dentistry, dental hygiene, dental and surgical
assisting, observing surgery in our office. If you specifically do not want an
observer in your surgery, please make this known.
This notice is effective as of April 14, 2003, and
we are required to abide by the terms of the Notice of Privacy Practices
currently in effect. We reserve the right to change the terms of our Notice of
Privacy Practices currently in effect. We reserve the right to change the terms
of our Notice of Privacy Practices and to make the new notice provisions
effective for all protected health information that we maintain. We will post
and you may request a written copy of a revised Notice of Privacy Practices from
this office.
You have recourse if you feel that your privacy protections have
been violated. You have the right to file a formal, written complaint with us
at the address below, or with the Department of Health & Human Services,
Office of Civil Rights, about violations of the provisions of this notice or
the policies and procedures of our office. We will not retaliate against you
for filing a complaint.
Please contact us for more information:
Jane Clark 930 16thAve Moline, Illinois 61265 (309)-797-1770
For
more information about HIPAA or To file a complaint:
The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington,
D.C. 20201
(202)619-0257
Toll Free:
1-877-696-6775