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RIVER CITY DENTAL
CARE®, INC.
NOTICE OF PRIVACY PRACTICES
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
We use and disclose health information about you for treatment,
payment, and healthcare operations. For example:
Treatment: We may use ordisclose
your health information to a dentist, physician or other
healthcare provider providing treatment to you.
Payment: We may use and disclose your health information
to obtain payment for services we provide to you.
Healthcare Operations: Wemay
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.
Your Authorization: Inaddition
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: Wemust
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 useor
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: Wewill
not use your health information for marketing communications
without your written authorization.
Required by Law: We may useor
disclose your health information when we are required to
do so by law.
Abuse or Neglect: We maydisclose
your health information to appropriate authorities if we
reasonably believe that you are a possible victim of abuse,
neglect, or 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.
National Security: We may discloseto
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 Reminders: We mayuse
or disclose your health information to provide you with
appointment reminders (such as voicemail messages, postcards,
or letters).
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 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 copies, we may charge you
$0.12 for each page, $12 per hour for staff time to locate
and copy your health information, and postage if you want
the copies mailed to you. 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: Youhave
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 rightto
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 abide by our agreement (except in an emergency).
Alternative Communication: Youhave
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.} Your
request must specify the alternative means or location,
and provide satisfactory explanation how payments will be
handled under the alternative means or location you request.
Amendment: You have the right to request that we amend your
health information. (Your request must be in writing, and
it must explain why the information should be amended.)
We may deny your request under certain circumstances.
Electronic Notice: If you receivethis
Notice on our Web site or by electronic mail (e-mail), you
are entitled to receive this Notice in written form.
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 wemay
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 complain to us using the contact information
listed at the end of this Notice. You also may submit a
written complaint to 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 privacyof
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.
Contact Officer: Brian Murray, Office Administrator
Telephone: (319) 337 - 6226
FAX: (319) 354 - 9650
Address: 1950 Lower Muscatine Ave., Iowa City, IA, 52240
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