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Notice
of Privacy Practices (2/03)
My
staff and I have been educated on the federal regulations related to HIPAA
(Health Insurance Portability & Accountability Act of 1996).
We have undergone extensive training so that we can protect the privacy
of your personal health information.
The
law protects the privacy of the health information we obtain in providing our
services to you. For example, your
protected health information includes your symptoms, test results, diagnoses,
treatment, health information from other providers, and billing and payment
information relating to these services. Federal
and state law allows us to use and disclose your protected health information
for purposes of treatment and health care operations.
State law requires us to get your authorization to disclose this
information for payment purposes.
Examples
of use and disclosures of protected health information:
 | For
treatment:
Information obtained by an assistant, hygienist, office staff,
dentist, or other member of our team will be recorded in your dental record
and used to help decide what care may be right for you.
We may also provide information to others providing you care.
This will help them stay informed about your care with us.
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| For
payment: We request payment from your health insurance
and/or you. Health insurance
plans need information from us about your dental care. Information provided to health plans may include your
diagnoses, procedures performed, or recommended treatment.
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| For
health care operations: We
analyze your dental records to assess quality and improve services. We may use and disclose dental records to review the
qualifications and performance of our health care providers and to train our
staff. We may contact you to
remind you about appointments and give you information about treatment
alternatives or other health related benefits. We may disclose your information to conduct or arrange
for services including 1) quality review by your health plan, 2) accounting,
legal, risk management, and insurance services, 3) audit functions,
including fraud and abuse detection and compliance programs.
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Your
health information rights:
The
health and billing records we create and store are the property of the practice.
The protected health information within it, however, generally belongs to
you. You have a right to:
| Receive,
read, and ask questions about this notice.
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| Ask
us to restrict certain uses and disclosures.
You must deliver this request in writing to us. We are not required to grant the request.
But we will comply with any request granted.
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| Request
and receive from us a paper copy of the most current Notice of Privacy
Practices for Protected Health Information.
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| Request
that you be allowed to see and get a copy of your protected health
information. You may make this
request in writing.
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| Ask
us to change your health information. You
may give us this request in writing. You
may write a statement of disagreement if your request is denied.
It will be stored in your dental record and included with any release
of your records.
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| When
you request, we will give you a list of disclosures of your health
information. The list will not
include disclosures to third-party payors.
You may receive this information without charge once every 12 months.
We will notify you of the cost involved if you request this
information more than once in 12 months.
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| Ask
that your health information be given to you by another means or at another
location. Please sign, date,
and give us your request in writing.
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| Cancel
prior authorizations to use or disclose health information by giving us a
written revocation. Your
revocation does not affect information that has already been released.
It also does not affect any key action taken before we have it.
Sometimes, you cannot cancel an authorization if its purpose was to
obtain insurance.
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For
help with these rights during normal business hours, please call 425.392.8992.
Our
responsibilities:
| Keep
your protected health information private.
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| Give
you this notice.
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| Follow
the terms of this notice.
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We
have the right to change our practices regarding the protected health
information we maintain. If we make
changes, we will update this notice. You
may receive the most recent copy of this notice by calling and asking for it, by
visiting our office to pick one up, or by getting it from our website,
www.theresacheng.com.
To
ask for help or file a complaint:
If
you have questions, want more information, or want to report a problem about the
handling of your protected health information, you may contact:
Pennie at Dr. Cheng’s office: 425.392.89892
If
you believe your privacy rights have been violated, you may discuss your
concerns with any staff member. You
may also deliver a written complaint to Dr. Cheng at our office.
You may also file a complaint with the U.S. Secretary of Health and Human
Services, 200 Independence Ave. S.W., Washington D.C., 20201, 877.696.6776
(toll-free)
We
respect your right to file a complaint with us or with the U.S. Secretary of
Health and Human Services. If you
complain, we will not retaliate against you.
We
may use and disclose your protected health information without your
authorization in these circumstances:
| Medical
researchers
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| Funeral
directors/coroners
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| Organ
procurement organizations
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| FDA
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| To
comply with workers’ compensation laws
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| Public
health safety
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| To
report suspected abuse
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| To
correctional institutions
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| To
law enforcement
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| For
health safety oversight
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| For
disaster relief
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| For
work related conditions which could affect employee health
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| To
the military authorities
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| For
judicial proceedings
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| For
special government functions |
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