Modern Family Dentistry

Policies and Accessibility Disclaimer

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Policies and Accessibility Disclaimer

POLICIES AND ACCESSIBILITY DISCLAIMER  

NOTICE OF PRIVACY PRACTICES 

Access Dental, LLC  

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE  USED OR DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS  INFORMATION. PLEASE REVIEW IT CAREFULLY. 

Effective Date: May 15,2023. This Notice was revised on May 6, 2023.  

Privacy Officer: Liana Pritchett 

Mailing Address: 446 S New St., Dover, DE 19904 

Telephone: 302-674-3303 

About This Notice 

We are required by law to maintain the privacy of Protected Health Information and to give you  this Notice explaining our privacy practices with regard to that information. You have certain  rights and we have certain legal obligations regarding the privacy of your Protected Health  Information, and this Notice also explains your rights and our obligations. We are required to  abide by the terms of the current version of this Notice.  

What is Protected Health Information?  

“Protected Health Information” is information that individually identifies you and that we create  or get from you or from another health care provider, health plan, your employer, or a health care  clearinghouse and that relates to (1) your past, present, or future physical or mental health or  conditions, (2) the provision of health care to you, or (3) the past, present, or future payment for  your health care.  

How We May Use and Disclose Your Protected Health Information  

We may use and disclose your Protected Health Information in the following circumstances:  

For Treatment. We may use or disclose your Protected Health Information to give you  medical treatment or services and to manage and coordinate your medical care. For  example, your Protected Health Information may be provided to a physician or other  health care provider (e.g., a specialist or laboratory) to whom you have been referred to  ensure that the physician or other health care provider has the necessary information to  diagnose or treat you or provide you with a service. 

For Payment. We may use and disclose your Protected Health Information so that we  can bill for the treatment and services you receive from us and can collect payment from  you, a health plan, or a third party. This use and disclosure may include certain activities  that your health insurance plan may undertake before it approves or pays for the health  care services we recommend for you, such as making a determination of eligibility or  coverage for insurance benefits, reviewing services provided to you for medical  necessity, and undertaking utilization review activities. For example, we may need to  give your health plan information about your treatment in order for your health plan to  agree to pay for that treatment.  

For Health Care Operations. We may use and disclose Protected Health Information  for our health care operations. For example, we may use your Protected Health  Information to internally review the quality of the treatment and services you receive and  to evaluate the performance of our team members in caring for you. We also may  disclose information to physicians, nurses, medical technicians, medical students, and  other authorized personnel for educational and learning purposes.  

• Appointment Reminders/Treatment Alternatives/Health-Related Benefits and  Services. We may use and disclose Protected Health Information to contact you to  remind you that you have an appointment for medical care, or to contact you to tell you  about possible treatment options or alternatives or health related benefits and services that  may be of interest to you.  

Minors. We may disclose the Protected Health Information of minor children to their  parents or guardians unless such disclosure is otherwise prohibited by law.  Research. We may use and disclose your Protected Health Information for research  purposes, but we will only do that if the research has been specially approved by an  authorized institutional review board or a privacy board that has reviewed the research  proposal and has set up protocols to ensure the privacy of your Protected Health  Information. Even without that special approval, we may permit researchers to look at  Protected Health Information to help them prepare for research, for example, to allow  them to identify patients who may be included in their research project, as long as they do  not remove, or take a copy of, any Protected Health Information. We may use and  disclose a limited data set that does not contain specific readily identifiable information  about you for research. However, we will only disclose the limited data set if we enter  into a data use agreement with the recipient who must agree to (1) use the data set only  for the purposes for which it was provided, (2) ensure the confidentiality and security of  the data, and (3) not identify the information or use it to contact any individual.  As Required by Law. We will disclose Protected Health Information about you when  required to do so by international, federal, state, or local law.  

To Avert a Serious Threat to Health or Safety. We may use and disclose Protected  Health Information when necessary to prevent a serious threat to your health or safety or  to the health or safety of others. But we will only disclose the information to someone  who may be able to help prevent the threat.  

Business Associates. We may disclose Protected Health Information to our business  associates who perform functions on our behalf or provide us with services if the  Protected Health Information is necessary for those functions or services. For example,  we may use another company to do our billing, or to provide transcription or consulting services for us. All of our business associates are obligated, under contract with us, to  protect the privacy and ensure the security of your Protected Health Information.  Organ and Tissue Donation. If you are an organ or tissue donor, we may use or disclose  your Protected Health Information to organizations that handle organ procurement or  transplantation – such as an organ donation bank – as necessary to facilitate organ or  tissue donation and transplantation.  

Military and Veterans. If you are a member of the armed forces, we may disclose  Protected Health Information as required by military command authorities. We also may  disclose Protected Health Information to the appropriate foreign military authority if you  are a member of a foreign military.  

Workers’ Compensation. We may use or disclose Protected Health Information for  workers’ compensation or similar programs that provide benefits for work-related injuries  or illness.  

Public Health Risks. We may disclose Protected Health Information for public health  activities. This includes disclosures to: (1) a person subject to the jurisdiction of the Food  and Drug Administration (“FDA”) for purposes related to the quality, safety or  effectiveness of an FDA-regulated product or activity; (2) prevent or control disease,  injury or disability; (3) report births and deaths; (4) report child abuse or neglect; (5)  report reactions to medications or problems with products; (6) notify people of recalls of  products they may be using; and (7) a person who may have been exposed to a disease or  may be at risk for contracting or spreading a disease or condition.  

Abuse, Neglect, or Domestic Violence. We may disclose Protected Health Information  to the appropriate government authority if we believe a patient has been the victim of  abuse, neglect, or domestic violence and the patient agrees or we are required or  authorized by law to make that disclosure.  

Health Oversight Activities. We may disclose Protected Health Information to a health  oversight agency for activities authorized by law. These oversight activities include, for  example, audits, investigations, inspections, licensure, and similar activities that are  necessary for the government to monitor the health care system, government programs,  and compliance with civil rights laws.  

Data Breach Notification Purposes. We may use or disclose your Protected Health  Information to provide legally required notices of unauthorized access to or disclosure of  your health information.  

Lawsuits and Disputes. If you are involved in a lawsuit or a dispute, we may disclose  Protected Health Information in response to a court or administrative order. We also may  disclose Protected Health Information in response to a subpoena, discovery request, or  other legal process from someone else involved in the dispute, but only if efforts have  been made to tell you about the request or to get an order protecting the information  requested. We may also use or disclose your Protected Health Information to defend  ourselves in the event of a lawsuit.  

Law Enforcement. We may disclose Protected Health Information, so long as applicable  legal requirements are met, for law enforcement purposes.  

Military Activity and National Security. If you are involved with military, national  security or intelligence activities or if you are in law enforcement custody, we may  disclose your Protected Health Information to authorized officials so they may carry out  their legal duties under the law. 

Coroners, Medical Examiners, and Funeral Directors. We may disclose Protected  Health Information to a coroner, medical examiner, or funeral director so that they can  carry out their duties.  

Inmates. If you are an inmate of a correctional institution or under the custody of a law  enforcement official, we may disclose Protected Health Information to the correctional  institution or law enforcement official if the disclosure is necessary (1) for the institution  to provide you with health care; (2) to protect your health and safety or the health and  safety of others; or (3) the safety and security of the correctional institution.  

Uses and Disclosures That Require Us to Give You an Opportunity to Object and Opt Out  

Individuals Involved in Your Care or Payment for Your Care. Unless you object, we  may disclose to a member of your family, a relative, a close friend or any other person  you identify, your Protected Health Information that directly relates to that person’s  involvement in your health care. If you are unable to agree or object to such a disclosure,  we may disclose such information as necessary if we determine that it is in your best  interest based on our professional judgment.  

Disaster Relief. We may disclose your Protected Health Information to disaster relief  organizations that seek your Protected Health Information to coordinate your care, or  notify family and friends of your location or condition in a disaster. We will provide you  with an opportunity to agree or object to such a disclosure whenever we practicably can  do so.  

Fundraising Activities. We may use or disclose your Protected Health Information, as  necessary, in order to contact you for fundraising activities. You have the right to opt out  of receiving fundraising communications.  

Your Written Authorization is Required for Other Uses and Disclosures  

The following uses and disclosures of your Protected Health Information will be made only with  your written authorization:  

  1. Most uses and disclosures of psychotherapy notes;
  2. Uses and disclosures of Protected Health Information for marketing purposes; and  3. Disclosures that constitute a sale of your Protected Health Information.  

Other uses and disclosures of Protected Health Information not covered by this Notice or the  laws that apply to us will be made only with your written authorization. If you do give us an  authorization, you may revoke it at any time by submitting a written revocation to our Privacy  Officer and we will no longer disclose Protected Health Information under the authorization. But  disclosure that we made in reliance on your authorization before you revoked it will not be  affected by the revocation.  

Your Rights Regarding Your Protected Health Information 

You have the following rights, subject to certain limitations, regarding your Protected Health  Information:  

Right to Inspect and Copy. You have the right to inspect and copy Protected Health  Information that may be used to make decisions about your care or payment for your  care. We have up to 30 days to make your Protected Health Information available to you  and we may charge you a reasonable fee for the costs of copying, mailing or other  supplies associated with your request. We may not charge you a fee if you need the  information for a claim for benefits under the Social Security Act or any other state or  federal needs-based benefit program. We may deny your request in certain limited  circumstances. If we do deny your request, you have the right to have the denial reviewed  by a licensed healthcare professional who was not directly involved in the denial of your  request, and we will comply with the outcome of the review.  

Right to a Summary or Explanation. We can also provide you with a summary of your  Protected Health Information, rather than the entire record, or we can provide you with an  explanation of the Protected Health Information which has been provided to you, so long  as you agrees to this alternative form and pay the associated fees.  

• Right to an Electronic Copy of Electronic Medical Records. If your Protected Health  Information is maintained in an electronic format (known as an electronic medical record or an  electronic health record), you have the right to request that an electronic copy of your record be  given to you or transmitted to another individual or entity. We will make every effort to provide  access to your Protected Health Information in the form or format you request, if it is readily  producible in such form or format. If the Protected Health Information is not readily producible  in the form or format you request your record will be provided in either our standard electronic  format or if you do not want this form or format, a readable hard copy form. We may charge you  reasonable, cost-based fee for the labor associated with transmitting the electronic medical  record.  

Right to Get Notice of a Breach. You have the right to be notified upon a breach of any  of your unsecured Protected Health Information.  

Right to Request Amendments. If you feel that the Protected Health Information we  have is incorrect or incomplete, you may ask us to amend the information. You have the  right to request an amendment for as long as the information is kept by or for us. A  request for amendment must be made in writing to the Privacy Officer at the address  provided at the beginning of this Notice and it must tell us the reason for your request. In  certain cases, we may deny your request for an amendment. If we deny your request for  an amendment, you have the right to file a statement of disagreement with us and we may  prepare a rebuttal to your statement and will provide you with a copy of any such  rebuttal.  

Right to an Accounting of Disclosures. You have the right to ask for an “accounting of  disclosures,” which is a list of the disclosures we made of your Protected Health  Information. This right applies to disclosures for purposes other than treatment, payment  or healthcare operations as described in this Notice. It excludes disclosures we may have  made to you, for a resident directory, to family members or friends involved in your care, or for notification purposes. The right to receive this information is subject to certain  exceptions, restrictions and limitations. Additionally, limitations are different for  electronic health records. The first accounting of disclosures you request within any 12- month period will be free. For additional requests within the same period, we may charge  you for the reasonable costs of providing the accounting. We will tell what the costs are,  and you may choose to withdraw or modify your request before the costs are incurred.  

Right to Request Restrictions. You have the right to request a restriction or limitation  on the Protected Health Information we use or disclose for treatment, payment, or health  care operations. You also have the right to request a limit on the Protected Health  Information we disclose about you to someone who is involved in your care or the  payment for your care, like a family member or friend. To request a restriction on who  may have access to your Protected Health Information, you must submit a written request  to the Privacy Officer. Your request must state the specific restriction requested and to  whom you want the restriction to apply. We are not required to agree to your request,  unless you are asking us to restrict the use and disclosure of your Protected Health  Information to a health plan for payment or health care operation purposes and such  information you wish to restrict pertains solely to a health care item or service for which  you have paid us “out-of-pocket” in full. If we do agree to the requested restriction, we  may not use or disclose your Protected Health Information in violation of that restriction  unless it is needed to provide emergency treatment.  

Out-of-Pocket-Payments. If you paid out-of-pocket (or in other words, you have  requested that we not bill your health plan) in full for a specific item or service, you have  the right to ask that your Protected Health Information with respect to that item or service  not be disclosed to a health plan for purposes of payment or health care operations, and  we will honor that request.  

Right to Request Confidential Communications. You have the right to request that we  communicate with you only in certain ways to preserve your privacy. For example, you  may request that we contact you by mail at a specific address or call you only at your  work number. You must make any such request in writing and you must specify how or  where we are to contact you. We will accommodate all reasonable requests. We will not  ask you the reason for your request.  

Right to a Paper Copy of This Notice. You have the right to a paper copy of this  Notice, even if you have agreed to receive this Notice electronically. You may request a  copy of this Notice at any time.  

How to Exercise Your Rights 

To exercise your rights described in this Notice, send your request, in writing, to our Privacy  Officer at the address listed at the beginning of this Notice. We may ask you to fill out a form  that we will supply. To exercise your right to inspect and copy your Protected Health  Information, you may also contact your physician directly. To get a paper copy of this Notice,  contact our Privacy Officer by phone or mail.  

Changes To This Notice

We reserve the right to change this Notice. We reserve the right to make the changed Notice  effective for Protected Health Information we already have as well as for any Protected Health  Information we create or receive in the future. A copy of our current Notice is posted in our  office and on our website.  

Complaints 

You may file a complaint with us or with the Secretary of the United States Department of  Health and Human Services if you believe your privacy rights have been violated.  

To file a complaint with us, contact our Privacy Officer at the address listed at the beginning of  this Notice. All complaints must be made in writing and should be submitted within 180 days of  when you knew or should have known of the suspected violation. There will be no retaliation  against you for filing a complaint.  

To file a complaint with the Secretary, mail it to: Secretary of the U.S. Department of Health and  Human Services, 200 Independence Ave, S.W., Washington, D.C. 20201. Call (202) 619-0257  (or toll free (877) 696-6775) or go to the website of the Office for Civil  

Rights, www.hhs.gov/ocr/hipaa/, for more information. There will be no retaliation against you  for filing a complaint.  

Notice to Website Viewers  

This website is provided for information and education purposes only. No doctor/patient  relationship is established by your use of this site. No diagnosis or treatment is being provided.  The information contained here should be used in consultation with a doctor of your choice. No  guarantees or warranties are made regarding any of the information contained within this web  site. This web site is not intended to offer specific medical, dental or surgical advice to anyone.  Further, this web site and Dr. Karen Rose, DDS take no responsibility for web sites hyper-linked  to this site and such hyperlinking does not imply any relationships or endorsements of the linked  sites.  

Privacy Policy  

If you require any more information or have any questions about our privacy policy, please feel  free to contact us. At www.accessdentalllc.com, the privacy of our visitors is of extreme  importance to us. This privacy policy document outlines the types of personal information that is  received and collected by www.accessdentalllc.com and how it is used.  

Notice Informing Individuals about Nondiscrimination and Accessibility 

Access Dental, LLC complies with applicable federal civil rights laws and does not discriminate  on the basis of race, color, national origin, age, disability, or sex. Access Dental, LLC does not  exclude people or treat them differently because of race, color, national origin, age, disability, or  sex. We provide free aids and services to people with disabilities to communicate effectively  with us, such as: qualified sign language interpreters through CyraCom, written information in large print and/or accessible electronic formats. We also offer language interpretation services  through CyraCom to people whose primary language is not English. If you need these services,  contact our Civil Rights Coordinator identified below. If you believe that Access Dental, LLC  has failed to provide these services or discriminated in another way on the basis of race, color,  national origin, age, disability, or sex, you can file a grievance with our Civil Rights Coordinator.  

Coordinator: Liana Pritchett Phone: 302-674-3303 Fax: 302-674-3304  Address: 446 S New St., Dover, DE 19904  

Email: lpritchett@accessdentalllc.com  

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance,  our Civil Rights Coordinator identified above is available to help you. You can also file a civil  rights complaint with the U.S. Department of Health and Human Services, Office for Civil  Rights electronically through the Office for Civil Rights Complaint Portal, available at  https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health  and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington,  DC 20201, 1-800-868-1019, 800537-7697 (TDD). Complaint forms are available at  http://www.hhs.gov/ocr/office/file/index.html.  

Nondiscrimination statement for significant publications and signification communications that  are small-size:  

Access Dental, LLC complies with applicable Federal civil rights laws and does not discriminate  on the basis of race, color, national origin, age, disability, or sex.  

Section 1557 of the Affordable Care Act Grievance Procedure 

It is the policy of Access Dental, LLC not to discriminate on the basis of race, color, national  origin, sex, age or disability. Access Dental, LLC has adopted an internal grievance procedure  providing for prompt and equitable resolution of complaints alleging any action prohibited by  Section 1557 of the Affordable Care Act (42 U.S.C. 18116) and its implementing regulations  at 45 CFR part 92, issued by the U.S. Department of Health and Human Services. Section 1557  prohibits discrimination on the basis of race, color, national origin, sex, age or disability in  certain health programs and activities. Section 1557 and its implementing regulations may be  examined in the office The Civil Rights Coordinator, who has been designated to coordinate the  efforts of Access Dental, LLC to comply with Section 1557, at the following address:  

Coordinator: Liana Pritchett Phone: 302-674-3303 Fax: 302-674-3304  Address: 446 S New St., Dover, DE 19904  

Email: lpritchett@accessdentalllc.com  

Any person who believes someone has been subjected to discrimination on the basis of race,  color, national origin, sex, age or disability may file a grievance under this procedure. It is  against the law for Access Dental, LLC to retaliate against anyone who opposes discrimination,  files a grievance, or participates in the investigation of a grievance. 

Procedure:  

Grievances must be submitted to the Section 1557 Coordinator within (60 days) of the  date the person filing the grievance becomes aware of the alleged discriminatory action.  

A complaint must be in writing, containing the name and address of the person filing it.  The complaint must state the problem or action alleged to be discriminatory and the  remedy or relief sought.  

The Section 1557 Coordinator (or her/his designee) shall conduct an investigation of the  complaint. This investigation may be informal, but it will be thorough, affording all  interested persons an opportunity to submit evidence relevant to the complaint. The  Section 1557 Coordinator will maintain the files and records of Access Dental, LLC  relating to such grievances. To the extent possible, and in accordance with applicable  law, the Section 1557 Coordinator will take appropriate steps to preserve the  confidentiality of files and records relating to grievances and will share them only with  those who have a need to know.  

The Section 1557 Coordinator will issue a written decision on the grievance, based on a  preponderance of the evidence, no later than 30 days after its filing, including a notice to  the complainant of their right to pursue further administrative or legal remedies.  

The person filing the grievance may appeal the decision of the Section 1557 Coordinator  by writing to the (Administrator/Chief Executive Officer/Board of Directors/etc.) within  15 days of receiving the Section 1557 Coordinator’s decision. The (Administrator/Chief  Executive Officer/Board of Directors/etc.) shall issue a written decision in response to the  appeal no later than 30 days after its filing.  

The availability and use of this grievance procedure does not prevent a person from pursuing  other legal or administrative remedies, including filing a complaint of discrimination on the basis  of race, color, national origin, sex, age or disability in court or with the U.S. Department of  Health and Human Services, Office for Civil Rights. A person can file a complaint of  discrimination electronically through the Office for Civil Rights Complaint Portal, which is  available at: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S.  Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH  Building, Washington, DC 20201.  

Complaint forms are available at: http://www.hhs.gov/ocr/office/file/index.html. Such complaints  must be filed within 180 days of the date of the alleged discrimination.  

Access Dental, LLC will make appropriate arrangements to ensure that individuals with  disabilities and individuals with limited English proficiency are provided auxiliary aids and  services or language assistance services, respectively, if needed to participate in this grievance  process. Such arrangements may include, but are not limited to, providing qualified interpreters,  providing taped cassettes of material for individuals with low vision, or assuring a barrier-free  location for the proceedings. The Section 1557 Coordinator will be responsible for such  arrangements.