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.
Levenson Smile is required by law to maintain the privacy of your Protected Health Information, to provide you with this notice of its legal duties and privacy practices with respect to your Protected Health Information and to notify you following a breach of unsecured Protected Health Information.
This notice is being issued to comply with the requirements of the Privacy Rules under the Health Insurance Portability and Accountability Act (“HIPAA Privacy Rules”). Individually identifiable information about your past, present or future health condition, the provision of health care to you, or payment for such health care is considered “Protected Health Information” (“PHI”).
We use and disclose PHI about you without your authorization for treatment, payment, and health care operations.
Treatment: We may disclose PHI to your other medical professionals for treatment purposes.
Payment: We use and disclose your PHI in order to fulfill our duty to provide you coverage, determine your benefits, and make payment for services provided to you. For example, we use and disclose your PHI in order to process your claims.
Health Care Operations: We use and disclose your PHI as a part of certain operations, such as quality improvement. For example, we may use and disclose your PHI to evaluate the quality of our services that were performed or to check for fraud and abuse or to help improve our methods in contacting you, so we can provide you
We may not, however, use or disclose any PHI that is considered genetic information under Federal Law for underwriting purposes.
Unless you object, we may disclose your PHI to a family member,
We may also use or disclose your PHI without your authorization for several other reasons. Subject to certain requirements, we may use or disclose your PHI without your authorization for public health purposes, auditing purposes, research studies, and emergencies.
We may disclose PHI in response to a court or administrative order, subpoena, discovery request or other lawful process if certain conditions are met and the required assurances are received. We provide PHI when otherwise required by law, such as for law enforcement purposes.
We may disclose your PHI to public health or other appropriate authorities to lessen a serious or imminent threat to the health or safety of you or the public. In other situations, not described here, we will ask for your written authorization before using or disclosing your PHI. If you choose to sign an authorization to allow disclosure of your PHI, you can later revoke that authorization to stop any future uses and disclosures (other than for treatment, payment and health care operations).
We reserve the right to change this notice at any time and for any reason. We reserve the right to make the revised or changed notice effective for PHI we currently maintain as well as any information received in the future. A copy of our most current notice will be posted at www.levensonsmile.com
In most cases, you have the right to view or get a copy of your PHI which is held in a particular record set by us. You also have the right to receive a list of instances where we have disclosed your PHI without your written authorization for reasons other than treatment, payment or health care operations.
If you believe that information in your record is incorrect or if important information is missing, you have the right to request that we correct the existing information or add the missing information.
You may request in writing that we not use or disclose your PHI for treatment, payment and health care operations except when specifically authorized by you, when required by law, or in emergency circumstances.
We will consider your request but are not legally required to accept it. You also have the right to receive confidential communications of PHI by alternative means or at alternative locations, if you clearly state that disclosure of all or part of your PHI could endanger you. You also have the right to receive notice following an unauthorized access, use or disclosure of your PHI if that unauthorized access, use or disclosure is considered a “breach” as defined by the HIPAA Privacy Rules.
We are required by law to protect the privacy of your information, provide this notice about our information practices, and follow the information practices that are described in this notice.
If you wish to inspect your records, receive a listing of disclosures, or correct or add to the information in your record, request a paper copy of this Notice or if you have any questions, complaints or concerns, please contact:
9 Linden St, Worcester, MA 01609
Phone: (855) 849-8255, Email: email@example.com
Effective Date of this Notice: 09/04/2018