Notices of Privacy Practices
This notice describes how medical information about you may be used and disclosed, as well as how you may get access to this information. Please review it carefully.
Polo Dental still respects your privacy. We understand that your personal health information is very sensitive. we will not disclose your personal health information to others unless you request us to do so in writing or unless the law authorizes us or require us to do so. The law protects the privacy of health information, we create and obtain in providing our care and services to you. For example, we protected health information include symptoms, test result, diagnosis, health information from other providers, billing and payment information related to these services. federal and state law allows us to use and disclose your protected health information for purpose of treatment and health care operations. State law requires us to get your authorization to disclose your information for payment purposes.
Example of use and Disclosures of Protected Health Information for Treatment, Payment and Health option.
For Treatment :
- Information obtained by Physician and other members of our healthcare team will be recorded in your medical report and used to help, decide, what care is best for you.
- We may also provide information to other providing your care. This will help them to stay informed about your care.
For payment :
- We request from your health insurance plan. Health plan needs information from us about your medical care. information provided to health plan may include diagnosis, Procedure performed or recommended care.
For Healthcare Information :
- We use your medical record to access quality and improve services.
- We may use and disclose the medical report to review the qualification and performance of our health care providers and to train our staff.
- We may contact you to remind you about appointments and inform you about treatment alternatives or other health-related benefit and services.
- We may use and disclose your information to conduct or arrange for services including :
- Medical review by your health plan
- Accounting, Legal, Risk management and insurance services.
- Audit function including fraud and abuse detection and compliance program.
Your Health Information Rights :
The health and billing record we create and store the property of practices the protected health information in it generally belongs to you. You have the right to :
- Receive Read and ask questions about this notice.
- Ask 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.
- Requestor receives a paper copy of the most current notice of privacy practices of protected health information.
- Request that you be allowed to see and get a copy of your protected health information . you may make this request in writing, We have a form available for this type of request. If you request copies a fee will be charged for expense including copies of staff time ($.83 for the first 30 pages, $.63 for additional pages and $19.00 For a clerical fee.). Postage will be additional if you wish to have us mail your information.
- Have a review a denial of access to your health information – except in certain circumstances.
- Ask us to change your health information. you may give us the request in writing. You may write a statement disagreement if your request is denied. It will be stored in your medical record. and included with any released of your records.
- When you request, we will give you closures of your health information. the list will not include disclosures to third-party payors. you may receive this information once every 12 months. we will notify you the cost involved about if you request this information more than once in every 12 months.
- Ask that your health information is given to you by another means or at another location. Please sign, date and give us the request in writing.
- Cancel prior authorization to use the disclose health information by giving us written revocation. Your revocation does not affect information that does not affect information that has already been released. It does not affect any action taken before we have it. Sometimes you can not cancel any authorization if its purpose was to obtain insurance.
For help with these rights during normal business hours, Please contact :
15 Noble Ave
Westfield, MA 01085
Our Responsibility :
We are required to :
- Keep the protected health information private.
- Give you this notice.
- Follow the term of this notice.
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 the notice by calling and asking for it. or by visiting our office to pick one up.
To ask for help or complain :
If you have questions, need more information, or want to report a problem about the handling of your protected health information, you may contact: Polo Dental
15 Noble Ave
Westfield, MA 01085
If you believe your privacy right has been violated, you may discuss your concern with any staff members. you may also deliver a written complaint to privacy officer at our practice. you may also file a complaint with the US Secretary of Health and Human Services.
We respect your right to file a complaint with us U.S secretary of Health and Human Services. If you complain, we are not retaliated against you.
Other Disclosures and uses of Protected Health Information
Notification to family and others :
Unless your object, We may release information about you to a friend or family members who are involved in your medical care. We may also give information to someones who help or pay for your care. We may tell your family and friends your condition that you are in the hospital. In addition, we may disclose health information about you to assist in disaster relief efforts.
You have the right to object to this use or disclosures of your information. If you object, We will not use or disclose it.
We may use or disclose your protected information without your authorization as follows :
- To comply with workers compensation law – if you make a workers Compensation claims.
- For public health and safety purposes as allowed or required by law ;
- To prevent or reduce a serious immediate threat to health or safety of a person or a public.
- To prevent health and legal authorities.
- To protect public health and safety
- To prevent and control disease, injuries or disabilities.
- To report vital statistics such as births or deaths.
- To report suspected abuse or neglected to public authorities.
- To correctional institutional, if you are in jail or prison as necessary for your health and safety for others.
- For law enforcement purposes such as when we receive a subpoena, court order, legal process or you are a victim of a crime.
- For health and safety oversight activities. For example, we may share health information to department of health
- For a work-related condition that could affect employee health for example. an employer may ask us to access health risk on a job site.
- To the militaries authorities of US the Foreign Military Personnel, for example, the law may require us to provide information necessary to a militant mission.
- In the course of Judicial / Administrative Proceeding at your request Or as directed by Subpoena or court order
Other uses and Disclosures of protected health information
- Uses and Disclosures not in this notice will be made only as allowed or required by the law or with your written authorization