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Practice
Covered By This Notice
This notice describes the privacy practices of the Office of
Gregory J. Conte D.M.D., M.S. and Paola
Guglielmoni, D.D.S., M.S. which includes the Doctors and all
employees.
How to Contact Us
If you have any questions or would like further information
about this notice, you can either write to us at 345 West Portal
Avenue, San Francisco, CA 94127 or call 415-664-4532.
Information Covered By This Notice
We create and maintain records about the dental care and services
you receive at the Office of Gregory J. Conte D.M.D., M.S. and Paola Guglielmoni, D.D.S., M.S.
Having these records helps us to provide you with quality care
and to comply with certain legal requirements. This notice applies
to health information about you that we create or receive and
that identifies you. This notice tells you about the ways we
may use and disclose health information about you. It also describes
your rights and certain obligations we have with respect to
your health information.
We are required by law to:
maintain the privacy of health information that identifies you;
give you this notice of our legal duties and privacy practices
with respect to that information; and
abide by the terms of our privacy notice that is currently in
effect
Copies of our Privacy Notice will be posted in our office and
are, at all times, available upon request.
How We May Use and Disclose Health Information About
You
We describe below the reasons we may use and disclose health
information about you. For each category, we will explain what
we mean and give you examples.
Treatment. We may use health information
about you to provide you with dental treatment or services.
We may disclose health information about you to dental specialists,
physicians, or other health care professionals involved in your
care. For example, a periodontist treating you for periodontal
disease may need to know if you have a heart condition because
it could necessitate antibiotics before treatment.
Payment. We may use and disclose your
health information so the treatment and services you receive
may be billed to, and payment may be collected from, an insurance
carrier or other entity. For example, we may need to give your
health insurance provider information about care you received
at our office so they will pay us or reimburse you for the services.
Health Care Operations. We
may use and disclose health information about you in connection
with a wide range of health care operations. These uses and
disclosures are necessary to run our practice and to help ensure
that our patients receive appropriate care. For example, we
may use health information about you to review our treatment
and services and evaluate the performance of our staff of health
care professionals.
Appointment Reminders. We may use
or disclose health information about you when contacting you
to remind you of a dental appointment. We may contact you by
using a postcard, letter, voicemail, or e mail.
Treatment Alternatives. We may use and disclose
health information about you to tell you about or recommend
possible treatment options or alternatives that may be of interest
to you.
Health-related Benefits and Services.
We may use and disclose health information about you to tell
you about health-related benefits and services that may be of
interest to you.
Disclosure to Individuals Involved in Your Care
or Payment for Your Care. We may disclose health
information about you to a family member or friend who is involved
with your care or payment for your care. If you do not object,
or if you are not present and we believe it is in your best
interest to do so, we may tell your family or others responsible
for your care of your location, condition, or death. In addition,
we may disclose health information about you to an entity assisting
in a disaster relief effort so your family or others responsible
for your care can be notified about your location, condition,
or death.
Disclosures Required by Law. We
may use or disclose health information about you to the extent
we are required by law to do so.
Public Health Activities. We may disclose
health information about you for certain public health activities
and purposes. These activities and purposes generally include
the following:
. preventing or controlling disease, injury or disability;
. reporting births or deaths;
. reporting child abuse or neglect;
. reporting adverse reactions to medications or foods;
. reporting product defects;
. notifying people of recalls of products they may be using;
and
. notifying a person who may have been exposed to a disease
or may be at risk for contracting or spreading a disease or
condition.
Victims of Abuse, Neglect or Domestic Violence.
Under certain circumstances, we may disclose to the appropriate
government authority health information about an individual
whom we believe is a victim of abuse, neglect or domestic violence.
We will make this disclosure only (i) if you agree or (ii) to
the extent required or authorized by law and we believe the
disclosure is necessary to prevent serious harm.
Health Oversight Activities. We may
disclose health information about you to a health oversight
agency for activities authorized by law. These oversight activities
include audits, investigations, inspections, licensure actions
and other activities necessary for the government to provide
appropriate oversight of the health care system, certain government
benefit programs, and compliance with certain civil rights laws.
Lawsuits and Legal Actions. If you
are involved in a lawsuit or other legal action, we may disclose
health information about you in response to a court or administrative
order. We also may disclose health information about you in
response to a subpoena, discovery request, or other lawful process
that is not ordered by a court, but only if efforts have been
made to tell you about the request or to obtain an order protecting
the information requested.
Law Enforcement Purposes. We may disclose
health information about you for a law enforcement purpose to
a law enforcement official:
. as required by law or in response to a court order, warrant,
subpoena, summons or similar process;
. to identify or locate a suspect, fugitive, material witness
or missing person;
. if you are an actual or suspected victim of a crime and you
agree to the disclosure or, under certain limited circumstances,
if we are unable to obtain your agreement;
. to alert law enforcement of your death if we suspect it may
have resulted from criminal conduct;
. if we believe the information shows evidence of criminal conduct
at our office; or
. if we are providing care in response to a medical emergency,
if necessary to report a crime; the location of the crime or
victims; or the identity, description or location of the person
who committed the crime.
Coroners, Medical Examiners and Funeral Directors.
We may disclose health information to a coroner
or medical examiner to identify a deceased person, determine
the cause of death or undertake other authorized duties. We
also may release health information to funeral directors as
necessary to carry out their duties.
Organ, Eye and Tissue Donation. We
may use or disclose health information about you to organ procurement
organizations or others that obtain, bank or transplant cadaveric
organs, eyes or tissue for donation and transplant.
Serious Threat to Health or Safety.
We may use or disclose health information about you if we believe
it is necessary to do so to prevent or lessen a serious threat
to anyone’s health or safety. We would make such a disclosure
only to someone able to help prevent or lessen the threat or,
under certain circumstances, if the disclosure is necessary
for law enforcement authorities to identify and apprehend an
individual.
Specialized Government Functions.
If you are a member of the armed forces, we may, under certain
circumstances, use and disclose health information about you
as required by military command authorities. We also may use
and disclose health information about foreign military personnel
to the appropriate foreign military authority. We may disclose
health information about you to authorized federal officials
to (i) conduct certain national security activities, (ii) provide
protection to the President or other authorized people, or (iii)
conduct certain investigations. We may disclose to a correctional
institution or law enforcement official having custody of an
individual health information about that individual.
Workers' Compensation. We may disclose
health information about you to comply with laws relating to
workers' compensation or similar programs that provide benefits
for work-related injuries or illness.
Other Uses of Health Information.
We will make other uses and disclosures of health information
not discussed in this notice only with your written authorization.
If you authorize us to use or disclose health information about
you, you may revoke that authorization at any time. Your revocation
must be in writing. If you revoke your prior authorization,
we will no longer use or disclose health information about you
for the reasons covered by that authorization. You cannot revoke
your authorization to the extent that we have already taken
action based on that authorization. For example, we are unable
to take back any disclosures we have already made with your
authorization.
Your Rights
Right of Access. You may inspect and request
a copy of certain health information we have about you. We have
forms for such requests. These requests must be made in writing
and must be directed to our contact officer listed on the first
page of this notice. We will provide a copy in a format you
request if it is readily producible. If not readily producible,
we will provide it in a hard copy format or other format that
is mutually agreeable. If you are the recipient of electronic
notice, you may obtain a paper copy upon request.
We will charge a reasonable, cost-based fee when asked to provide
copies of your health information. Charges will include costs
for copying at 25 cents per page, postage, and staff time at
the rate of $20.00 dollars per hour. If you request a summary
of your health information, we will provide it, charging staff
time at the hourly rate shown above. If you have any questions
about our fees for these services, please contact us using the
contact information provided above.
Right to Amend. If you believe that
health information we have about you is incorrect or incomplete,
you may ask us to amend the information. Such requests must
be made in writing and must include a reason to support the
request. Under some circumstances, we may deny such a request,
but you are entitled to a written response within 60 days of
our receipt of your written request.
Right to Request Restrictions. You
may request that we restrict uses or disclosures of certain
health information about you to carry out treatment, payment,
or health care operations. We may not (and are not required
to) agree to requested restrictions. We will not use or disclose
any health information about you in violation of any restrictions
that we agree to other than in providing emergency treatment.
Confidential Communications: Alternative
Means, Alternative Locations. You may ask to receive
communications of health information by alternative means or
at an alternative location. We will accommodate all reasonable
requests. You must provide this type of request to us in writing
and provide an alternative method of contact or alternative
address. We will provide an estimate of the fee for this service
in advance and ask that you provide information as to how payment
will be handled.
Accounting of Disclosures. You have
a right to receive an accounting of disclosures we have made
of health information about you for the six years prior to the
date that the accounting is requested except for disclosures
to carry out treatment, payment, health care operations, and
certain other disclosures. The first such accounting we provide
within any 12 month period will be without charge to you. We
will charge a reasonable, cost-based fee for each subsequent
request for an accounting within a 12 month period. We will
notify you in advance of this fee.
Right to a Paper Copy of this Notice.
You have the right to a paper copy of this notice. You may ask
us to give you a copy of the notice at any time. Even if you
have agreed to receive the notice electronically, you may still
obtain a paper copy. To obtain a paper copy, ask any staff member.
Changes to This Notice
We reserve the right to change the terms of this notice and
to make the changed notice provisions effective for all health
information we have about you or create or receive in the future.
We will promptly revise, post, and distribute a revised notice
whenever there is a material change to the uses or disclosures,
individual’s rights, our legal duties, or other privacy
practices discussed in this notice. Our privacy notice will
contain on the first page, in the top right-hand corner, the
effective date.
Complaints
If you have any complaints about your privacy rights or how
your health information has been used or disclosed, you may
file a complaint with us by contacting:
Gregory J. Conte D.M.D., M.S. and Paola
Guglielmoni, D.D.S., M.S
345 West Portal Avenue
San Francisco, CA 94127
Tel: 415-664-4532
You may also file a written complaint with the U.S. Department
of Health and Human Services by contacting:
The U.S. Department of Health and Human Services
200 Independence Avenue, S.W., Washington, D.C. 20201
Toll Free: 1-877-696-6775
The privacy of your health information is important to us. We
will not retaliate against you in any way if you choose to file
a complaint. |
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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.
