THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.
We will never share your information with anyone without your permission!
If you have any questions about this notice and/or want to exercise the rights below, please contact TN Center for Oral, Facial & Implant Surgery by dialing the main facility number at 615.713.2553.
Each time you visit a hospital, physician, or other healthcare provider, a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, a plan for future care or treatment, and billing-related information. This notice applies to all of the records of your care generated by the facility, whether made by facility personnel, agents of the facility, or your personal doctor. Your personal doctor may have different policies or notices regarding the doctor’s use and disclosure of your health information created in the doctor’s office or clinic.
We are required by law to maintain the privacy of your health information, provide you a description of our privacy practices, and to notify you following a breach of unsecured protected health information. We will abide by the terms of this notice.
Uses and Disclosures
The following categories describe examples of the way we use and disclose health information:
For Treatment: We may use health information about you to provide you treatment or services. We may disclose health information about you to doctors, nurses, technicians, medical students, or other personnel who are involved in taking care of you. For example: a doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. We may also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him or her in treating you.
For Payment: We may use and disclose health information about your treatment and services to bill and collect payment from you, your insurance company or a third party payer. For example, we may need to give your insurance company information about your surgery so they will pay us or reimburse you for the treatment. We may also tell your health plan about treatment you are going to receive to determine whether your plan will cover it.
Business Associates: There are some services provided in our organization through contracts with business associates. Examples include physician services in the emergency department and radiology, certain laboratory tests, and a copy service we use when making copies of your health record. When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we’ve asked them to do and bill you or your third-party payer for services rendered. To protect your health information, however, business associates are required by federal law to appropriately safeguard your information.
Organized Health Care Arrangement: This facility and its medical staff members have organized and are presenting you this document as a joint notice. Information will be shared as necessary to carry out treatment, payment and health care operations. Physicians and caregivers may have access to protected health information in their offices to assist in reviewing past treatment as it may affect treatment at the time.
Health Information Exchange/Regional Health Information Organization: Federal and state laws may permit us to participate in organizations with other healthcare providers, insurers, and/or other health care industry participants and their subcontractors in order for these individuals and entities to share your health information with one another to accomplish goals that may include but not be limited to: improving the accuracy and increasing the availability of your health records; decreasing the time needed to access your information; aggregating and comparing your information for quality improvement purposes; and such other purposes as may be permitted by law.
As required by law. We may disclose information when required to do so by law.
Law Enforcement: We may disclose health information to a law enforcement official for purposes such as providing limited information to locate a missing person or report a crime.
For Judicial or Administrative Proceedings: We may disclose protected health information as permitted by law in connection with judicial or administrative proceedings, such as in response to a court order, search warrant or subpoena.
We may also use and disclose health information:
•To remind you that you have an appointment for medical care;
•To assess your satisfaction with our services;
•To tell you about possible treatment alternatives;
•To tell you about health–related benefits or services;
When disclosing information, primarily appointment reminders and billing/collections efforts, we may leave messages on your answering machine/voice mail.
- 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 this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
•You may also check our website to view a copy of the notice by clicking on the Notice of Privacy Practices link.
CHANGES TO THIS NOTICE
We reserve the right to change this notice and the revised or changed notice will be effective for information we already have about you as well as any information we receive in the future. The current notice will be posted in the facility and on our website and include the effective date.
HIPAA ACKNOWLEDGMENT AND CONSENT FORM
PATIENT HIPAA ACKNOWLEDGMENT AND CONSENT FORM
Date of Birth:_________________________________________________________
______ (Patient initials) Notice of Privacy Practices. I acknowledge that I have received the practice’s Notice of Privacy Practices, which describes the ways in which the practice may use and disclose my healthcare information for its treatment, payment, healthcare operations and other described and permitted uses and disclosures, I understand that I may contact the facility designated on the notice if I have a question or complaint. I understand that this information may be disclosed electronically by the Provider and/or the Provider’s business associates. To the extent permitted by law, I consent to the use and disclosure of my information for the purposes described in the practice’s Notice of Privacy Practices.
______ (Patient initials) Release of Information. I hereby permit practice and the physicians or other health professionals involved in the inpatient or outpatient care to release healthcare information for purposes of treatment, payment, or healthcare operations.
Healthcare information may be released to any person or entity liable for payment on the Patient’s behalf in order to verify coverage or payment questions, or for any of purpose related to benefit payment. Healthcare information may also be released to my employer designee when the services delivered are related to a claim under worker’s compensation.
Federal and state laws may permit this facility to participate in organizations with other healthcare providers, insurers, and/or other health care industry participants and their subcontractors in order for these individuals and entities to share my health information with one another to accomplish goals that may include but not be limited to: improving the accuracy and increasing the availability of my health records; decreasing the time needed to access my information; aggregating and comparing my information for quality improvement purposes; and such other purposes as may be permitted by law. I understand that this facility may be a member of one or more such organizations. This consent specifically includes information concerning psychological conditions, psychiatric conditions, intellectual disability conditions, genetic information, chemical dependency conditions and/or infectious diseases including, but not limited to, blood borne diseases, such as HIV and AIDS.
Disclosures to Friends and/or Family Members
I hereby authorize TN Center for Oral, Facial & Implant Surgery to disclose my personal protected dental/health information as specified in this authorization form to the following personal contacts (ex: mother, father, spouse, etc.).
Patient may revoke or modify this specific authorization and that revocation or modification must be in writing.
Consent to Email for Appointment Reminders or Other Healthcare Communications
Patients in our practice may be contacted via email to remind you of an appointment, to obtain feedback on your experience with our healthcare team, and to provide general health reminders/information.
If at any time I provide an email address at which I may be contacted, I consent to receiving appointment reminders and other healthcare communications/information at that email address from TN Center for Oral, Facial & Implant Surgery.
The email that I authorize to receive emails for appointment reminders and general health reminders/feedback/information is______________________________________.
Revocation I hereby revoke my request for future communications via email. __ I hereby revoke my request to receive any future appointment reminders, feedback, and general health via email. NOTE: This revocation only applies to communications from this Practice.
Patient Name: _____________________________________________________________________
Patient/Patient Representative Signature: _______________________________________________
Consent for Photographing or Other Recording for Security and/or Health Care Operations
____ (Patient Initials) I consent to photographs, videotapes, digital or audio recordings, and/or images of me being recorded for security purposes and/or the practice’s health care operations purposes (e.g., quality improvement activities). I understand that the facility retains the ownership rights to the images and/or recordings. I will be allowed to request access to or copies of the images and/or recordings when technologically feasible unless otherwise prohibited by law. I understand that these images and/or recordings will be securely stored and protected. Images and/or recordings in which I am identified will not be released and/or used without a specific written authorization from me or my legal representative unless it is for treatment, payment or health care operations purposes or otherwise permitted or required by law.
____ (Patient Initials) I do not consent to photographs, videotapes, digital or audio recordings, and/or images of me being recorded for security purposes and/or the practice’s health care operations purposes (e.g., quality improvement activities).
Patient Signature: _____________________________________________________________
Patient Name (Printed): ________________________________________________________
Date: ____________________________ DOB: ________________________________