1861 E. Madison, Suite 400 & 500
DERBY, KS  67037

Notice of Privacy Practices


This notice describes how your health information may be used and disclosed by our office and your rights to access this information. It is effective April 17th, 2014, and applies to all protected information contained in your record at this dental office. We have the following duties regarding the maintenance, use and disclosure of your health record:

(1) We are required by law to maintain the privacy of the protected health information in your record and to provide you with this notice of our legal duties to privacy and practices with respect to that information.

(2) We are required to abide by the terms of this Notice currently in effect.

(3) We reserve the right to change the terms of this Notice at any time, making the new provisions effective for all health information and records that we have and continue to maintain. All changes in the notice will be prominently displayed and available at our office.

There are a number of situations in which we may use or disclose to other persons or entities your confidential health information. Certain uses and disclosures will require you to sign an acknowledgement that you have received this Notice of Privacy Practices. These include treatment, payment, and health care operations. Any use or disclosure of your protected health information required for anything other than treatment, payment, or health care operations requires you to sign and Authorization. Certain disclosures that are required by law, or under emergency circumstances, may be made without your acknowledgement or authorization. Under any circumstances, we will use or disclose only the minimum amount of information necessary from your medical records to accomplish the intended purpose of the disclosure.

We will attempt in good faith to obtain your signed Acknowledgement that you received this Notice to use and disclose your confidential medical information for the following purposes. These examples are not meant to be exhaustive, but do describe the types of uses and disclosures that may be made by our office on once you have provided consent.

We may use your information for the purposes of:

-Treatment: We will use your health information to make decisions about the provision, coordination, or management of your healthcare, including analyzing or diagnosing your condition and determining the appropriate treatment for that condition. It may also be necessary to share your health information with another health care provider whom we need to consult with respect to your care.

-Payment: We may need to use or disclose information in your health record to obtain reimbursement from you, from your health-insurance carrier, or from another insurer for our services rendered to you. This may include determinations of eligibility or coverage under the appropriate health plan, pre-certification and pre-authorization of services or review of for the purpose of reimbursement. This information may also be used for billing, claims management and collection purposes, and related healthcare data processing through our system.

There are certain circumstances under which we may use or disclose your health information without first obtaining your Acknowledgement or Authorization. Those circumstances generally involve public health and oversight activities, law-enforcement activities, judicial and administrative proceedings, and in the event of death. Specifically, we may be required to report to certain agencies information concerning certain communicable diseases, sexually transmitted diseases or HIV/AIDS status. We may also be required to report instances of suspected or documented abuse, neglect, or domestic violence. We are required to report to appropriate agencies and law enforcement officials information that you or another person is an immediate threat of danger to health or safety as a result of violent activity. We must also provide health information when ordered by a court of law to do so. We may contact you from time to time to provide appointment reminders or information about treatment about treatment alternatives or other health related benefits and services that may be of interest to you. You should be aware that our office and treatment areas are not completely isolated. We will try to speak quietly to you in a manner reasonably calculated to avoid disclosing your health information to others. However, complete privacy may not be possible in this setting. If you would prefer to discuss items related to your health information in a private room, please let us know and we will do our best to accommodate your wishes.

Communication Barriers and Emergencies: We may use and disclose your protected heath information if we attempt to obtain consent from you but are unable to do so because of substantial communication barriers and we determine, using professional judgment, that you intent to consent to use or disclose under the circumstances.

Except as indicated above, your health information will not be used or disclosed to any other person or entity without your specific authorization, which may be revoked at any time. In particular, except to the extent disclosure has been made to governmental entities required by law to maintain the confidentiality of the information, information will not be further disclosed to any other person or entity with respect to information concerning mental-health treatment, drug and alcohol abuse, HIV/AIDS or sexually transmitted diseases that may be contained in your health records. We likewise will not disclose your health-record information to an employer for purposes of making employment decisions, to a liability insurer or attorney as a result of injuries sustained in an automobile accident, or to educational authorities, without your written authorization.

I have read and understand these rights attributed to the Health Insurance Portability and Accountability Act (HIPPA). I have had the opportunity to ask questions and I am satisfied with the conditions met by the statutes.