Notice of privacy practices—
This notice describes how health information about you may be used and disclosed and how you can get access to this information. please review it carefully. The privacy of your health information is important to us.
Our Legal Duty—
Federal and state laws require us to maintain the privacy of your health information. We are also required by law to give you this notice about our privacy practices, our legal duties, and your rights concerning your health information. We are required to follow the privacy practices described in this notice commencing April 14, 2003 and continuing until replaced.
We reserve the right to change our privacy practices and the terms of this notice at any time, provided such applicable law permits such change. We reserve the right to make the changes in our privacy practices and applicable notice(s) and the new terms of our notice effective for all health information that we maintain, including the health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will update this notice and make the new notice available upon request.
You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice.
Uses and Disclosure of Health Information—
We use and disclose health information about you for treatment, payment, and health care operations. Examples include the following.
Treatment –– We may use your health information for treatment or disclose it to a dentist, physician, or other health care provider rendering treatment to you.
Payment –– We may use and disclose your health information to obtain payment for services we provide to you. We may also disclose your health information to another health care provider or entity that is subject to federal privacy rules for its payment activities.
Health Care Operations –– We may disclose and use your health information for our health care operations. Health care operations include quality assessment and improvement activities, reviewing the competence or qualifications of health care professionals, evaluating practitioner performance, conducting training programs, accreditation certification, licensing or credentialing activities. We may disclose your health information to another health care provider or organization that is subject to the federal privacy rules and that has a relationship with you to support some of their health operations. We may disclose your information to help these organizations conduct quality assessment and improvement activities, review the competence or qualifications of health care professionals, or detect or prevent health care fraud and abuse.
On Your Authorization –– You may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you provide such authorization, you may revoke it in writing at any time. Your revocation will not affect any uses or disclosures permitted by your authorization while it was in effect. Unless you provide written authorization, we cannot use or disclose your health information for any reason except those described in this notice.
To Your Friends and Family –– We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your health care or with payment for your health care. Before we can disclose your health information to these people, we will provide you with an opportunity to object to our use of said disclosure. If you are not present, or in the event of your incapacity or an emergency, we will disclose your medical information based on our professional judgment of whether the disclosure would be in your best interest. We may use our professional judgment and our experience with common practice(s) to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information. We may use or disclose information about you to notify or assist in notifying a person involved in your care, or your location and general condition.
Appointment Reminder –– We may use or disclose your health information to provide you with appointment reminders (such as voicemail, postcards, letters, email, or text to mobile devices).
Disaster Relief –– We may use or disclose your health information to a public or private entity authorized by law or its charter to assist in disaster relief efforts.
Public Benefit –– We may use or disclose your health information as authorized by law for the following purposes deemed to be in the public interest or benefit as required by law: for public health activities; including disease and vital statistic reporting, child abuse reporting, FDA oversight, and to employees regarding work-related illness or injury; to report adult abuse, neglect, or domestic violence; to health oversight agencies; in response to court and administrative orders and other lawful processes; to law enforcement officials pursuant to subpoenas and other lawful processes, concerning crime victims, suspicious deaths, crimes on our premises, reporting crimes in emergencies, and for purposes of identifying or locating a suspect or other person; to coroners, medical examiners, and funeral directors; to an organ procurement organization; to avert a serious threat to health or safety; in connection with certain research activities; to the military and to federal officials for lawful intelligence, counter-intelligence, and national security; to correctional institutions regarding inmates; and as authorized by state worker’s compensation laws.
Access –– You have the right to review or request copies of your health information with limited exceptions. You may request that we provide copies in formats other than photocopies. We will use the format you request unless we are not able to practically do so. You must submit a written request to obtain access to your health information. You may request access by sending a letter to the address at the end of this notice. If you request copies, we reserve the right to charge you a reasonable, cost-based fee that may include labor, copying costs, and postage. If you request an alternative format, we may charge a cost-based fee for providing your health information in the requested format. If you prefer, we may—but are not required to—prepare a summary or explanation of your health information for an additional fee. For more information regarding fees, contact our office.
You have the right to receive a list of instances in which we or our business associates disclosed your health information over the last 6 years. That list will not include disclosures for treatment, payment, health care operations (as authorized by you) and for certain other activities. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
Restriction –– You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to those additional restrictions; but if we do, we will abide by our agreement (except in an emergency). Any agreement we make to a request for additional restrictions must be signed in writing by a person authorized to make such an agreement on our behalf. Your request is not binding unless our agreement is in writing.
Alternative Communication –– You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. You must make your request in writing. You must specify in your request the alternative means or location and provide satisfactory explanation regarding how you will handle payment under the alternative means or location you request.
Amendment –– You have the right to request that we amend your health information. Your request must be in writing, and it must explain why we should amend the information. We may deny your request under certain circumstances.
Questions and Complaints—
If you want more information about our privacy practices or have questions or concerns, please contact our office. If you believe that we may have violated your privacy rights, incorrectly made a decision about access to your health information, incorrectly responded to a request you made to amend or restrict the use or disclosure of your health information, or you wish for us to communicate with your by alternative means, please contact our office. We support your right to the privacy of your health information.
Provider Contact Office—
Patrick W. Kutas, D.D.S.
7512 Corporate Centre Drive Germantown, TN 38138
Telephone: (901) 754-2273
Fax: (901) 754-2447