You have the right to request the opportunity to inspect and receive a copy of PHI about you in certain records that are maintained by the participating Dental Practice (as defined in the Notice of Privacy Practice) comprising the Smilegivers Professional Corporation/ SmileCare Dental & Braces PC/ My Family Dentist Cooperative (as defined in the Notice of Privacy Practice) and its authorized agent Smilegivers Professional Corporation/ SmileCare Dental & Braces PC/ My Family Dentist, Inc., (collectively, “Smilegivers Professional Corporation/ SmileCare Dental & Braces PC/ My Family Dentist,” “we” or “us”). This includes your dental and billing records but does not include psychotherapy notes or information gathered or prepared for a civil, criminal or administrative proceeding. We may deny your request to inspect and copy PHI only in limited circumstances. To inspect and copy PHI, please contact our Privacy Officer. If you request a copy of PHI about you, we may charge you a reasonable fee for the copying, postage, labor and supplies used in meeting your request.
AMEND RECORDS REQUEST
You have the right to request that we amend PHI about you as long as such information is kept by or for our office. To make this type of request, you must submit your request in writing to our Privacy Official. You must also give us a reason for your request. We may deny your request in certain cases, including if it is not in writing or if you do not give us a reason for the request.
ACCOUNTING OF DISCLOSURES REQUEST
You have the right to request an “accounting” of certain disclosures that we have made of PHI about you. This is a list of disclosures made by us during a specified period of up to six years, other than disclosures made: for treatment, payment and healthcare operations; for use in or related to a facility directory; to family members or friends involved in your care; to you directly; pursuant to an authorization of you or your personal representative; for certain notification purposes (including national security, intelligence, correctional and law enforcement purposes); as incidental disclosures that occur as a result of otherwise permitted disclosures; as part of a limited data set of information that does not directly identify you; and before April 14, 2003. To make a request, please contact our Privacy Official listed below. The first list that you request in a 12-month period will be free, but we may charge you for our reasonable costs of providing additional lists in the same 12-month period. We will tell you about these costs, and you may choose to cancel your request at any time before costs are incurred.
ALTERNATIVE COMMUNICATIONS REQUEST
You have a right to request to receive communications about protected health information by alternative means or at an alternative location. A request for confidential communications of protected health information must be submitted in writing to our Privacy Officer listed below. We will accommodate all reasonable requests and, if the request is accepted, will communicate you in a manner consistent with your request.
FURTHER RESTRICTIONS REQUEST
You have the right to request additional restrictions on the PHI that we may use or disclose for treatment, payment and healthcare operations. You may also request additional restrictions on our disclosure of PHI to certain individuals involved in your care that otherwise are permitted by the Privacy Rule. We are not required to agree to your request. If we do agree to your request, we are required to comply with our agreement except in certain cases, including where the information is needed to treat you in the case of an emergency. To request restrictions, you must make your request in writing to our Privacy Official. In your request, please include (1) the information that you want to restrict; (2) how you want to restrict the information (for example, restricting use to this office, only restricting disclosure to persons outside this office, or restricting both); and (3) to whom you want those restrictions to apply.
The primary obligation for compliance with this policy will be with the Dental Practice you selected on the Smilegivers Professional Corporation/ SmileCare Dental & Braces PC/ My Family Dentist website or our mobile application (“Application”), both controlled by Smilegivers Professional Corporation/ SmileCare Dental & Braces PC/ My Family Dentist (collectively “Site”). You have a legal right to file a formal complaint with us if you believe your privacy rights have been violated. You will not be retaliated against in any way for filing a complaint with us. Should you have any questions, comments or complaints you may direct all inquiries to Privacy Official at:
Smilegivers Professional Corporation/ SmileCare Dental & Braces
8725 Marbach Road, #201
San Antonio, TX 78227
Telephone: (210) 495-2222
Updated November 27, 2017
Copyright © 2017 Smilegivers Professional Corporation/ SmileCare Dental & Braces.