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This
web site is provided for information and education purposes only. No
doctor/patient relationship is established by your use of this site.
No diagnosis or treatment is being provided. The information
contained here should be used in consultation with a dentist of your
choice. No guarantees or warranties are made regarding any of the
information contained within the web site. This web site is not
intended to offer specific medical or dental advice to anyone. Dr.
George A. Hankerson and Dr. Brent Kvittem are licensed to practice in the state of
Minnesota and this
web site is not intended to solicit patients from other states.
Further, this web site and Drs. Hankerson & Kvittem take no responsibility for
web sites hyper-linked to this site and such hyper-linking does not imply
any relationships or endorsements.
Copyright:
Information and names within this web site may be subject to copyright and
trademark protection with all rights reserved. Duplication or use
without the expressed written permission by Children's Dental Care Inc. subjects the violator to both civil and criminal penalties.
HEALTH INFORMATION PRIVACY
POLICIES & PROCEDURES
These Health Information Privacy Policies &
Procedures implement our obligations to protect the privacy of
individually identifiable health information that we create, receive, or
maintain as a healthcare provider.
We implement these Health Information Privacy Policies and Procedures as a
matter of sound business practice; to protect the interests of our
patients; and to fulfill our legal obligations under the Health Insurance
Portability and Accountability Act of 1996 ("HIPAA"), its implementing
regulations at 45 CFR Parts 160 and 164 (65 Fed. Reg 82462 (Dec. 28,
2000)) ("Privacy Rules"), as amended (67 Fed. Reg. 53182 [Aug. 14, 2002]),
and state law that provides greater protection or rights to patients than
the Privacy Rules.
As a member of our workforce or as our Business Associate, you are
obligated to follow these Health Information Privacy Policies & Procedures
faithfully. Failure to do so can result in disciplinary action, including
termination of your employment or affiliation with us.
These Policies & Procedures address the basics of HIPAA and the Privacy
Rules that apply in our dental practice. They do not attempt to cover
everything in the Privacy Rules. The Policies & Procedures sometimes refer
to forms we use to help implement the policies and to the Privacy Rules
themselves when added detail may be needed.
Please note that while the Privacy Rules speak in terms of "individual"
rights and actions, these Policies & Procedures use the more familiar word
"patient" instead; "patient" should be read broadly to include prospective
patients, patients of record, former patients, their authorized
representatives, and any other "individuals" contemplated in the Privacy
Rules.
If you have questions or doubts about any use or disclosure of
individually identifiable health information or about your other
obligations under these Health Information Privacy Policies & Procedures,
the Privacy Rules or other federal or state law, please contact our
office. This policy was adopted effective 4/14/03
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1. General Rule: No Use or Disclosure
Our dental office must not use or disclose protected health information
(PHI), except as these Privacy Policies & Procedures permit or require.
2. Acknowledgement and Optional Consent
Our dental office will make a good faith effort to obtain a written
acknowledgement of receipt of our Notice of Privacy Practices (see Section
9) from a patient before we use or disclose his or her protected health
information (PHI) for treatment, to obtain payment for that treatment, or
for our healthcare operations (TPO).
Our dental office’s use or disclosure of PHI for our payment activities
and healthcare operations may be subject to the minimum necessary
requirements (see Section 7).
Our dental office will become familiar with our state’s privacy laws. If
required by our state law, or as directed by the dentist, we will also
seek Consent from a patient before we use or disclose PHI for TPO purposes
– in addition to obtaining an Acknowledgement of receipt of our Notice of
Privacy Practices.
a) Obtaining Consent – If consent is to be obtained, upon the individual’s
first visit as a patient (or next visit if already a patient), our dental
office will request and obtain the patient’s written Consent for our use
and disclosure of the patient’s PHI for treatment, payment, and healthcare
operations.
Any consent we obtain must be on our Consent form, which we may not alter
in any way. Our dental office will include the signed Consent form in the
patient’s chart.
b) Exceptions – Our dental office does not have to obtain the patient’s
Consent in emergency treatment situations; when treatment is required by
law; or when communications barriers prevent consent.
c) Consent Revocation – A patient from whom we obtain consent may revoke
it at any time by written notice. Our dental office will include the
revocation in the patient’s chart. There is space at the bottom of our
Consent form where the patient can revoke the consent.
d) Applicability – Consent for use or disclosure of PHI should not be
confused with informed consent for dental treatment. This section applies
to our practice.
3. Authorization
In some cases we must have proper, written Authorization from the patient
(or the patient’s personal representative) before we use or disclose a
patient’s PHI for any purpose (except for TPO purposes) or as permitted or
required without consent or authorization (see Sections 3, 4, or 5).
Our dental office will use the Authorization form. We will always act in
strict accordance with an Authorization.
a) Authorization Revocation – A patient may revoke an authorization at any
time by written notice. Our dental office will not rely on an
Authorization we know has been revoked.
b) Authorization from Another Provider – Our dental office will use or
disclose PHI as permitted by a valid Authorization we receive from another
healthcare provider.
Our dental office may rely on that covered entity to have requested only
the minimum necessary protected PHI. Therefore, our dental office will not
make our own "minimum necessary" determination, unless we know that the
Authorization is incomplete, contains false information, has been revoked,
or has expired.
c) Authorization Expiration – Our dental office will not rely on an
Authorization we know has expired.
4. Oral Agreement
Our dental office may use or disclose a patient’s PHI with the patient’s
Oral Agreement or if the patient is unavailable subject to all applicable
requirements.
Our dental office may use professional judgment and our experience with
common practice to make reasonable inferences of the patient’s best
interest in allowing a person to act on behalf of the patient to pick up
dental/medical supplies, X-rays, or other similar forms of PHI.
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5. Permitted Without Acknowledgement, Consent Authorization or Oral
Agreement
Our dental office may use or disclose a patient’s PHI in certain
situations, without Authorization or Oral Agreement. In our dental office,
these disclosures are not likely to be frequent.
a) Verification of Identity – Our dental office will always verify the
identity of any patient, and the identity and authority of any patient’s
personal representative, government or law enforcement official, or other
person, unknown to us, who requests PHI before we will disclose the PHI to
that person.
Our dental office will obtain appropriate identification and, if the
person is not the patient, evidence of authority. Examples of appropriate
identification include photographic identification card, government
identification card or badge, and appropriate document on government
letterhead. Our dental office will document the incident and how we
responded.
b) Uses or Disclosures Permitted under this Section 5 – The situations in
which our dental office is permitted to use or disclose PHI in accordance
with the procedures set out in this Section 5 are listed below.
Our dental office may disclose a patient’s PHI to that patient on request.
Our dental office may disclose to a patient’s personal representative PHI
relevant to the representative capacity. We will not disclose to a
personal representative we reasonably believe may be abusive to a patient
any PHI we reasonably believe may promote or further such abuse.
Our dental office will not use or disclose a patient’s PHI for fundraising
purposes without the patient’s Authorization.
Our dental office will not use or disclose PHI for marketing without a
patient’s Authorization unless the marketing is in the form of a
promotional gift of nominal value that we provide, or face-to-face
communications between us and the patient.
Our dental office may use or disclose PHI in the following types of
situations, provided procedures specified in the Privacy Rules are
followed:
For public health activities;
To health oversight agencies;
To coroners, medical examiners, and funeral directors;
To employers regarding work-related illness or injury;
To the military;
To federal officials for lawful intelligence, counterintelligence, and
national security activities;
To correctional institutions regarding inmates;
In response to subpoenas and other lawful judicial processes;
To law enforcement officials;
To report abuse, neglect, or domestic violence;
As required by law;
As part of research projects; and
As authorized by state worker’s compensation laws.
6. Required Disclosures
Our dental office will disclose protected health information (PHI) to a
patient (or to the patient’s personal representative) to the extent that
the patient has a right of access to the PHI (see Section 10); and to the
U.S. Department of Health and Human Services (HHS) on request for
complaint investigation or compliance review.
Our dental office will use the disclosure log to document each disclosure
we make to HHS.
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7. Minimum Necessary
Our dental office will make reasonable efforts to disclose, or request of
another covered entity, only the minimum necessary protected health
information (PHI) to accomplish the intended purpose.
There is no minimum necessary requirement for disclosures to or requests
by one another in our dental office or by a healthcare provider for
treatment; permitted or required disclosures to, or for disclosure
requested and authorized by, a patient; disclosures to HHS for compliance
reviews or complaint investigations; disclosures required by law; or uses
or disclosures required for compliance with the HIPAA Administrative
Simplification Rules.
a) Routine or Recurring Requests or Disclosures – Our dental office will
follow the policies and procedures that we adopt to limit our routine or
recurring requests for our disclosures of PHI to the minimum reasonably
necessary for the purpose.
b) Non-Routine or Non-Recurring Requests or Disclosures – No non-routine
or non-recurring request for or disclosure of PHI will be made until it
has been reviewed on a patient-by-patient basis against our criteria to
ensure that only the minimum necessary PHI for the purpose is requested or
disclosed.
c) Other’s Requests – Our dental office will rely, if reasonable for the
situation, on a request to disclose PHI being for the minimum necessary,
if the requester is: (a) a covered entity; (b) a professional (including
an attorney or accountant) who provides professional services to our
practice, either as a member of our workforce or as our Business
Associate, and who represents that the requested information is the
minimum necessary; (c) a public official who represents that the
information requested is the minimum necessary; or (d) a researcher
presenting appropriate documentation or making appropriate representations
that the research satisfies the applicable requirements of the Privacy
Rules.
d) Entire Record – Our dental office will not use, disclose, or request an
entire record, except as permitted in these Policies & Procedures or
standard protocols that we adopt reflecting situations when it is
necessary.
e) Minimum Necessary Workforce Use – Our dental office will use only the
minimum necessary PHI needed to perform our duties.
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8. Business Associates
Our dental office will obtain satisfactory assurance in the form of a
written contract that our Business Associates will appropriately safeguard
and limit their use and disclosure of the protected health information
(PHI) we disclose to them.
These Business Associate requirements are not applicable to our
disclosures to a healthcare provider for treatment purposes. The Business
Associate Contract Terms document contains the terms that federal law
requires be included in each Business Associate Contract.
a.) Breach by Business Associate – If our dental office learns that a
Business Associate has materially breached or violated its Business
Associate Contract with us, we will take prompt, reasonable steps to see
that the breach or violation is cured.
If the Business Associate does not promptly and effectively cure the
breach or violation, we will terminate our contract with the Business
Associate, or if contract termination is not feasible, report the Business
Associate’s breach or violation to the U.S. Department of Health and Human
Services (HHS).
9. Notice of Privacy Practices
Our dental office will maintain a Notice of Privacy Practices as required
by the Privacy Rules.
a) Our Notice – Our dental office will use and disclose PHI only in
conformance with the contents of our Notice of Privacy Practices. We will
promptly revise a Notice of Privacy Practices whenever there is a material
change to our uses or disclosures of PHI to legal duties, to the patients’
rights or to other privacy practices that render the statements in that
Notice no longer accurate.
Form 1, Notice of Privacy Practices, found in this Privacy Kit, contains
the terms that federal law requires.
b) Distribution of Our Notice – Our dental office will provide our Notice
of Privacy Practices to any person who requests it, and to each patient no
later than the date of our first service delivery after April 14, 2003.
Our dental office will have our Notice of Privacy Practices available for
patients to take with them. We will also post our Notice of Privacy
Practices in a clear and prominent location where it is reasonable to
expect patients seeking services from us will be able to read the Notice.
c) Acknowledgement of Notice – Our dental office will make a good faith
effort to obtain from the patient a written Acknowledgement of receipt of
our Notice of Privacy Practices.
Our dental office shall use Form 2, Acknowledgement of Receipt of Notice
of Privacy Practices, found in this Privacy Kit, to obtain the
Acknowledgement. If we cannot obtain written Acknowledgement from the
patient, we will use the form to document our attempt and the reason why
written Acknowledgement was not signed by the patient.
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10. Patients’ Rights
Our dental office will honor the rights of patients regarding their PHI.
a) Access – With rare exceptions, our dental office must permit patients
to request access to the PHI we or our Business Associates hold.
No PHI will be withheld from a patient seeking access unless we confirm
that the information may be withheld according to the Privacy Rules. We
may offer to provide a summary of the information in the chart. The
patient must agree in advance to receive a summary and to any fee we will
charge for providing the summary. Our dental office will contact our
Business Associates to retrieve any PHI they may have on the patient.
b) Amendment – Patients have the right to request to amend their PHI and
other records for as long as our dental office maintains them.
Our dental office may deny a request to amend PHI or records if: (a) we
did not create the information (unless the patient provides us a
reasonable basis to believe that the originator is not available to act on
a request to amend); (b) we believe the information is accurate and
complete; or (c) we do not have the information.
Our dental office will follow all procedures required by the Privacy Rules
for denial or approval of amendment requests. We will not, however,
physically alter or delete existing notes in a patient’s chart. We will
inform the patient when we agree to make an amendment, and we will contact
our Business Associates to help assure that any PHI they have on the
patient is appropriately amended. We will contact any individuals whom the
patient requests we alert to any amendment to the patient’s PHI. We will
also contact any individuals or entities of which we are aware that we
have sent erroneous or incomplete information and who may have acted on
the erroneous or incomplete information to the detriment of the patient.
When we deny a request for an amendment, we will mark any future
disclosures of the contested information in a way acknowledging the
contest.
c) Disclosure Accounting – Patients have the right to an accounting of
certain disclosures our dental office made of their PHI within the 6 years
prior to their request. Each disclosure we make, that is not for treatment
payment or healthcare operations, must be documented showing the date of
the disclosure, what was disclosed, the purpose of the disclosure, and the
name and (if known) address of each person or entity to whom the
disclosure was made. The Authorization or other documentation must be
included in the patient’s record. We use the patient’s chart to track each
disclosure of PHI as needed to enable us to fulfill our obligation to
account for these disclosures.
We are not required to account for disclosures we made: (a) before April
14, 2003; (b) to the patient (or the patient’s personal representative);
(c) to or for notification of persons involved in a patient’s healthcare
or payment for healthcare; (d) for treatment, payment, or healthcare
operations; (e) for national security or intelligence purposes; (f) to
correctional institutions or law enforcement officials regarding inmates;
or (g) according to an Authorization signed by the patient or the
patient’s representative; (h) incident to another permitted or required
use disclosure.
We will temporarily suspend the accounting of any disclosure when
requested to do so pursuant according to the Privacy Rules by health
oversight agencies or law enforcement officials. We may charge for any
accounting that is more frequent than every 12 months, provided the
patient is informed of the fee before the accounting is provided. We will
contact our Business Associates to assure we include in the accounting any
disclosures made by them for which we must account.
d) Restriction on Use or Disclosure – Patients have the right to request
our dental office to restrict use or disclosure of their PHI, including
for treatment, payment, or healthcare operations. We have no obligation to
agree to the request, but if we do, we will comply with our agreement
(except in an appropriate dental/medical emergency).
We may terminate an agreement restricting use or disclosure of PHI by a
written notice of termination to the patient. We will contact our Business
Associates whenever we agree to such a restriction to inform the Business
Associate of the restriction and its obligations to abide by the
restriction. We will document in the patient’s chart any such agreed to
restrictions.
e) Alternative Communications – Patients have the right to request us to
use alternative means or alternative locations when communicating PHI to
them. Our dental office will accommodate a patient’s request for such
alternative communications if the request is reasonable and in writing.
Our dental office will inform the patient of our decision to accommodate
or deny such a request. If we agree to such a request, we will inform our
Business Associates of the agreement and provide them with the information
necessary to comply with the agreement.
f) Applicability – Our dental office will be aware of and respect these
patients’ rights regarding their PHI, even though in most situations
patients are unlikely to exercise them.
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11. Staff Training and Management, Complaint Procedures, Data Safeguards,
Administrative Practices
a) Staff Training and Management
* Training – Our dental office will train all members of our workforce in
these Privacy Policies & Procedures, as necessary and appropriate for them
to carry out their functions. We will complete the privacy training of our
existing workforce by April 14, 2003.
After April 14, 2003, our dental office will train each new staff member
within a reasonable time after the member starts. We will also retain each
staff member whose functions are affected either by a material change in
our Privacy Policies and Procedures or in the member’s job functions,
within a reasonable time after the change.
Form 7, Staff Review of Policies and Procedures, can be used to have
workforce members acknowledge they have received and read a copy of these
Policies and Procedures.
*Discipline and Mitigation – Our dental office will develop, document,
disseminate, and implement appropriate discipline policies for staff
members who violate our Privacy Policies & Procedures, the Privacy Rules,
or other applicable federal or state privacy law.
Staff members who violate our Privacy Policies & Procedures, the Privacy
Rules or other applicable federal or state privacy law will be subject to
disciplinary action, possibly up to and including termination of
employment.
b) Complaints – Our dental office will implement procedures for patients
to complain about our compliance with our Privacy Policies and Procedures
or the Privacy Rules. We will also implement procedures to investigate and
resolve such complaints.
The Complaint form can be used by the patient to lodge the complaint. Each
complaint received must be referred to management immediately for
investigation and resolution. We will not retaliate against any patient or
workforce member who files a Complaint in good faith.
c) Data Safeguards – Our dental office will "add to" and strengthen these
Privacy Policies & Procedures with such additional data security policies
and procedures as are needed to have reasonable and appropriate
administrative, technical, and physical safeguards in place to ensure the
integrity and confidentiality of the PHI we maintain.
Our dental office will take reasonable steps to limit incidental uses and
disclosures of PHI made according to an otherwise permitted or required
use or disclosure.
d) Documentation and Record Retention – Our dental office will maintain in
written or electronic form all documentation required by the Privacy Rules
for six years from the date of creation or when the document was last in
effect, whichever is greater.
e) Privacy Policies & Procedures – Only Dr. George A. Hankerson and Dr.
Brent Kvittem may change these Privacy Policies & Procedures.
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12. State Law Compliance
Our dental office will comply with the privacy laws of each state that has
jurisdiction over our practice, or its actions involving protected health
information (PHI), that provide greater protections or rights to patients
than the Privacy Rules.
13. HHS Enforcement
Our dental office will give the U.S. Department of Health and Human
Services (HHS) access to our facilities, books, records, accounts, and
other information sources (including individually identifiable health
information without patient authorization or notice) during normal
business hours (or at other times without notice if HHS presents
appropriate lawful administrative or judicial process).
We will cooperate with any compliance review or complaint investigation by
HHS, while preserving the rights of our practice.
14. Designated Personnel
Our dental office will designate a Privacy Officer and other responsible
persons as required by the Privacy Rules.
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