Effective Date: April 14, 2003
Last Revision Date: None

NOTICE OF PRIVACY PRACTICES

This Notice describes how dental and medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

OUR DUTIES REGARDING YOUR HEALTH INFORMATION

We respect the confidentiality of your health information and recognize that information about your health is personal. We are committed to protecting your health information and to informing you of your rights regarding such information. We are also required by law to protect the privacy of your protected health information and to provide you with notice of these legal duties. This Notice explains how, when and why we typically use and disclose health information and your privacy rights regarding your health information. In our Notice, we refer to our uses and discloses of health information as our “Privacy Practices.” Protected health information generally includes information that we create or receive that identifies you and your past, present or future health status or care or the provision of or payment for that health care. We are obligated to abide by these Privacy Practices as of the effective date listed above.

We may, however, change our Privacy Practices in the future and specifically reserve our right to change the terms of this Notice and our Privacy Practices. We will communicate any change in our Notice and Privacy Practices as described at the end of this Notice. Any changes that we make in our Privacy Practices will affect any protected health information that we maintain.

Generally, our Privacy Practices strive:

* To make sure that health information that identifies you is kept private;

* To give you this Notice of our Privacy Practices and legal duties with respect to protected health information;

* To follow the terms of the Notice that is currently in effect; and

* To make a good faith effort to obtain from you a written acknowledgement that you have received or been given an opportunity to receive this Notice.

HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU

We use and disclose your protected health information in a variety of circumstances and for different reasons. Many of these uses and disclosures require your prior authorization. There are situations, however, in which we may use and disclose your heath information without your authorization. Many of these uses and disclosures will occur with your treatment, for payment of health services or for our health care operations. There are additional situations, however, where the law permits or requires us to use and disclose your health information without your authorization. These situations will also be described in this section of the Notice. Specifically, we may use and disclose your protected health information as follows:

For Treatment, Payment and Health Care Operations

1. For Your Treatment. We may use and/or disclose you protected health information to dentists, physicians, nurses, assistants, hygienists, dietitians, technicians, physical therapists or other health care personnel who are involved in your care and who will provide you with medical treatment or services.
2. For Payment of Health Services that You Receive. We may use and/or disclose your protected health information to bell and receive payment for the health services that you receive from us.

3. For Our Health Care Operations. We perform many activities to help assess and improve the services that we provide. Such activities include, among others, participating in dental assisting training programs or education, performing quality reviews, conducting patient opinion surveys, developing clinical guidelines and protocols, engaging in case management and care coordination, business management, insurance or legal compliance reviews or participating in accreditation surveys. These activities are referred to as “health care operations.” We may use and/or disclose health information for purposes of any of these health care operations.

4. For Another Provider’s Treatment, Payment or Health Care Operations. The law also permits us to disclose your protected health information to another health care provider involved with your treatment to enable that provider to treat you and get paid for those services as well as for that provider’s health care operation activities involving quality reviews, assessments or compliance audits.

5. Special Circumstances When We May Disclose Your Heath Information related to Treatment, Payment or Health Care Operations. After removing direct identifying information (such as your name, address, and social security number) from the health information, we may use your health information for research, public health activities or other health care operations (such as business planning). While only limited identifying information will be used, we will also obtain certain assurances from the recipient of such health information that they will safeguard the information and only use and disclose the information for limited purposes.

Additionally, we may disclose health information to outside organizations or providers in order for them to provide services to you on our behalf. We will also seek written assurances form these providers to safeguard the health information that they receive.

For Permitted or Required by Law Activities.

There are situations where we may use and/or disclose your health information without first obtaining your written authorization for purposes other that for treatment, payment, or health care operations. Except for the specific situations where the law requires us to use and disclose information (such as reports of abuse or neglect to social services), we have listed all these permitted uses and disclosures in this section.

1. For Public Health Activities. We may use or disclose health information to a public health authority that is authorized by law to collect or receive information in order to report, among other things, communicable diseases and child abuse, or to the F.D.A. to report medical device or product related events. In certain limited situations, we may also disclose health information to notify a person exposed to a communicable disease.

2. For Health Oversight Activities. We may disclose health information to a health oversight agency that includes, among others, an agency of the federal or state government that is authorized by law to monitor the health care system.

3. For Law Enforcement Activities. We may disclose limited health information in response to a law enforcement official’s request for information to identify or locate a victim, a suspect, a fugitive, a material witness or a missing person (including individuals who have died) or for reporting a crime that has occurred on our premises or that may have caused a need for emergency services.

4. For Judicial and Administrative Proceedings. We may disclose health information in response to a subpoena or order of a court or administrative tribunal.

5. To Coroners, Medical Examiners, and Funeral Directors. We may release health information to a coroner or medical examiner to identify a deceased person or to determine cause of death.

6. For Purposes of Research. We conduct and participate in dental, medical, social and other types of research. Most research projects are subject to a special approval process to evaluate the proposed research project and its use of health information before we use or disclose health information. In certain circumstances, however, we may disclose health information to people preparing to conduct a research project to help them determine whether a research project can be carries out or will be useful, so long as the heath information they review does not leave our premises.

7. To Avoid Harm to a Person or for Public Safety. We may use and disclose health information if we believe that the disclosure is necessary to prevent or lesson a serious threat or harm to the public or the health or safety of another person.

8. For Specialized Government Functions. We may use and disclose health information of certain military individuals, for specific government security needs, or as needed by correctional institutions.

9. For Workers’ Compensation Purposes. We may use and disclose health information to comply with the workers’ compensation laws or other similar programs.

10. For Appointment Reminders and to Inform You of Health Related Products or Services. We may use or disclose your health information to contact you for dental appointment or other scheduled services, or to provide you with information about treatment alternatives or other health-related products and services.

When your preferences will guide our use or disclosure.

While the law permits certain uses and disclosures without you authorization, the law also provides you with an opportunity to inform us of your preferences, in certain limited situations, concerning the use or disclosure of your health information. For these limited uses and disclosures, we may simply ask and you may simply tell us your preference concerning the use or disclosure of your health information.

All Other Uses and Disclosures Require Your Prior Written Authorization.

For situations not generally described in our Notice, we will ask for your written authorization before we use or disclose your health information. You may revoke that authorization, in writing, at any time to stop future disclosures of you information. Information previously disclosed, however, will not be requested to be returned nor will you revocation affect any action that we have already taken. In addition, if we collected the information in connection with a research study, we are permitted to use and disclose that information to the extent it is necessary to protect the integrity of the research study.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

This portion of our Notice describes your individual privacy rights regarding your health information and how you may exercise those rights.

Requesting Restrictions of Certain Uses and Disclosures of Health Information.

You may request, in writing, a restriction on how we use or disclose your protected health information for your treatment, for payment of your health care services, or for activities related to our health care operations. You may also request a restriction on what health information we may disclose to someone who is involved in you care, such as a family member or friend.
We are not required to agree to your request. Additionally, any restriction that we may approve will not affect any use or disclosure that we are legally required or permitted to make under the law.

Requesting Confidential Communications

You may request and receive reasonable changes in the manner or the location where we may contact you for appointment reminders, lab results or other related information. You must make your request in writing and specify the alternate method or location where you wish to be contacted and how you will handle payment for you health services. We will accommodate your reasonable request, but in determining whether your request is reasonable, we may consider the administrative difficulty it may impose on us.

Inspecting and Obtaining Copies of Your Health Information.

You may ask to look at and obtain a copy of your health information. You must make your request in writing.
We may charge a fee for copying or preparing a summary of requested health information. We will respond to your request for health information within 30 days of receiving your request unless your health information is not readily accessible or the information is maintained in an off-site storage location.

Requesting a Change in Your Health Information.

You may request, in writing, a change or addition to your health information. The law limits your ability to change or add to your health information. These limitations include whether we created or include the health information within our dental records or if we believe that the health information is accurate and complete without any changes. Under no circumstances will we erase or otherwise delete original documentation in your health information.

Requesting an Accounting of Disclosures of you Health Information.

You may ask, in writing, for an accounting of certain types of disclosures of your health information. The law excludes form an accounting many of the typical disclosures, such as those made to care for you, to pay for your health services, or where you provided your written authorization to the disclosure. Generally, we will respond to your request within 60 days of receiving your request unless we need additional time.

Obtaining a Notice of Our Privacy Practices.

We provide you with our Notice to explain and inform you of our Privacy Practices. You may also take a copy of this Notice with you. Even if you have requested this Notice electronically, you may request a paper copy at any time. You may also view or obtain a copy of this Notice at our website:
www.RomanelliDental.com

CHANGES TO THIS NOTICE

We reserve the right to change this Notice concerning our Privacy Practices affecting all the health information that we now maintain, as well as information that we may receive in the future. We will provide you with the revised Notice on our website.

COMPLAINTS

We welcome an opportunity to address any concerns that you may have regarding the privacy of your health information. If you believe that the privacy of your health information has been violated, you may file a complaint with the individual(s) listed in Section VII of this Notice. You also may file a complaint with the Secretary of the U.S. Department of Health and Human Services.
You will not be penalized or retaliated against for filing a complaint.

CONTACT PERSONS

For questions, concerns, requests or complaints, you may contact us as follows:

Romanelli Dental
Privacy Officer
7110 Wornall Road
Kansas City, MO 64114