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.
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Georgia Regents (GRU) University College of Dental Medicine (CDM) follows the privacy practices in this Notice. For purposes of this Notice, the CDM is defined as all professional staff, employees, residents, students and volunteers who perform services at a number of treatment sites including: CDM’s Pre-Doctoral, Graduate, Dental Hygiene, Post-Operative, Faculty Practice, Residency clinics and Center for Clinical & Translational Craniofacial Research.
If you have any questions after reading this Notice, please contact our Enterprise Privacy Officer.
We understand that your health information is personal; therefore, we are committed to protecting your information in accordance with applicable laws and accreditation standards regarding patient privacy. As a patient at a CDM dental clinic, the treatment you receive is recorded in a health record. In order to provide you with comprehensive quality health care, we share your health record with health care providers involved in your care. We also use your health information, to the extent necessary, to conduct our operations, to collect payment for services and to comply with the laws that govern health care. We will not use or disclose your health information for any other purposes without your permission.
This Notice describes your rights and certain obligations we have regarding the use and disclosure of health information. This Notice also tells you about the ways in which we may use or disclose health information about you.
Applicable federal and Georgia law requires us to:
You have the following rights regarding health information we maintain about you:
Right to Inspect and Request a Copy of your Health Record
You have the right to inspect and request a copy of your health information as long as the information is kept by us, this includes dental and billing records. To inspect and have your health information copied; please submit your written request on a form that will be provided to you upon your request. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other expenses associated with your request. For health information in a designated record set that is maintained in an electronic format, you can request an electronic copy of such information. There may be a charge for these copies.
Under certain limited circumstances, we may deny your request to inspect and obtain a copy of your health information. If you are denied access, you may request that the denial be reviewed. Another unbiased licensed dental care professional, chosen by the CDM, will review your request and the denial. We will comply with the outcome of the review.
Right to Amend your Health Information
If you believe that the health information we have about you is incorrect or incomplete, you may ask us to amend it. You have the right to amend your health information as long as the information is kept by the CDM. To amend your health information, please submit your written request on a form that will be provided to you upon your request.
We may deny your request for an amendment if it is not in writing or it does not include a reason to support the request. We also may deny your request if you ask us to amend information that:
If we deny part or your entire request, we will provide a written explanation.
Right to an Accounting of Disclosures of your Health Information
You have a right to receive an “accounting of disclosures” of certain disclosures of your health information. To request an accounting of disclosures of your health information, please submit your written request on a form that will be provided to you, upon your request. Your request must state a time period that may not be longer than three years and may not include dates before April 14, 2003. Your request should indicate in what form you want the list (for example, on paper, electronically). The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restriction
You have the right to request certain restrictions of our use or disclosure of your health information. We are not required to agree to your request in most cases. But if we agree to the restriction, we will comply with your request unless the information is needed to provide you emergency treatment. We will agree to restrict disclosure of health information about an individual to a health plan if the purpose of the disclosure is to carry out payment or health care operations and the health information pertains solely to a service for which the individual, or a person other than the health plan, has paid us for in full. For example, if a patient pays for a service completely out of pocket and asks us not to tell his/her insurance company about it, we will abide by this request. A request for restriction should be made in writing. To request a restriction you must contact the CDM Business Office. We reserve the right to terminate any previously agreed-to restrictions (other than a restriction we are required to agree to by law). We will inform you of the termination of the agreed-to restriction and such termination will only be effective with respect to health information created after we inform you of the termination.
To request a restriction, please submit your written request on a form that will be provided to you upon your request. You must tell us: (1) what information you want to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply; for example, disclosures to your spouse.
Right to Request Confidential Communications
If you believe that a disclosure of all or part of your health information may endanger you, you may request in writing that we communicate with you in an alternative manner or at an alternative location. For example, you may ask that all communications be sent to your work address. Your request must specify the alternative means or location for communication with you. It also must state that the disclosure of all or part of the health information in a manner inconsistent with your instructions would put you in danger. We will accommodate a request for confidential communications that is reasonable and that states that the disclosure of all or part of your protected health information could endanger you.
Right to be Notified of a Breach
You have the right to be notified in the event that we, or one of our Business Associates, discovers a breach of unsecured protected health information involving your health information.
Right to a Paper Copy of This Notice
You have the right to receive 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 previously agreed to receive this Notice electronically, you are still entitled to a paper copy of this Notice. You may obtain a copy of this Notice from your direct dental health provider, a representative from the CDM Business Office or from our website at the address listed at the end of this Notice.
The following categories describe some of the different ways that we use and disclose your health information. To respect your privacy, we will try to limit the amount of information that we use or disclose to that which is the minimum necessary to accomplish the purpose of the use or disclosure.
We may use or disclose your health information among health care providers involved in your care, For example, your dentist may share information about your condition with the pharmacist to discuss appropriate medications or with radiologists or other consultants in order to make a diagnosis.
We will use and disclose information to other health care providers to assist in the payment of your bills. We will use it to send bills and collect payment from you, your insurance company, or other payers, such as Medicare, for the care, treatment, and other related services you receive. We may tell your health insurer about a treatment your doctor has recommended to obtain prior approval to determine whether your plan will cover the cost of the treatment.
Health Care Operations
We may use and disclose your health information in connection with our health care operations. Health care operations include quality assessment and improvement activities, reviewing the competence or qualification of dental health care professionals, evaluation practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credential activities.
We may use or disclose your health information to an outside company that performs various services for us. This includes, but is not limited to, auditing, accreditation, legal services, and a billing agency. These outside companies are called "business associates" and they contract with us to keep any health information received from us confidential in the same way we do. These companies may create or receive health information on our behalf.
We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters) and to communicate necessary information about your appointment.
Treatment Alternatives and Health-Related Benefits & Services
We may use and disclose your health information to tell you about or recommend possible treatment alternatives or health-related benefits and services that may be of interest to you.
Family Members and Friends
If you agree (do not object), or we reasonably infer that there is no objection, we may disclose health information about you to a family member, relative, or another person identified by you who is involved in your health care or payment for your health care. If you are not present or are incapacitated or it is an emergency or disaster relief situation, we will use our professional judgment to determine whether disclosing limited health information is in your best interest under the circumstances. We may disclose health information to a family member, relative, or another person who was involved in the health care or payment for health care of a deceased individual if not inconsistent with the prior expressed preferences of the individual that are known to us. But you also have the right to request a restriction on our disclosure of your health information to someone who is involved in your care. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, health supplies, x-rays, or other similar forms of health information.
As an academic dental center, research is one of our missions. Under certain circumstances we may use and share your health information for certain kinds of research. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another for the same condition. We may also allow your health information to be used by people who are preparing to conduct a research project. All research projects, however, are subject to a special approval process. In some instances, the law allows us to do some research using your health information without your approval.
We may use certain information, such as your name, address, telephone number, name of physician, department used, or dates of service, to contact you in the future to seek donations for our community service programs, patient care, health research and education. We may also share this information with an institutional-related charitable foundation that will contact you to raise money. If you do not want to be contacted as part of these fundraising events, you have a right to opt-out of receiving fundraising communication.
Marketing or Sale of health information
Uses and disclosures of health information for marketing purposes (which encourage you to purchase or use a product or service) and disclosures that constitute the sale of health information require your written authorization.
We do not have to obtain your permission to use your health information when communicating face-to-face (including providing a product sample) or when providing a promotional gift of nominal value (including pens, calendars, or other merchandise that generally promotes our health center and clinics).
Health Information Exchanges
We may make your health information available electronically through state, regional, or national information exchange services which help make your health information available to other healthcare providers who may need access to it in order to provide care or treatment to you. For example, if you are admitted on an emergency basis to a hospital that participates in the health information exchange, the exchange will allow us to make your health information available electronically to those who need it to treat you. We may also participate in various electronic health information exchanges that facilitate access to health information by other health care providers who provide you care.
A patient’s participation in a health information exchange is voluntary and subject to a patient’s right to opt-out. If you do not want to participate in a health information exchange, please notify our Enterprise Privacy Officer.
To Prevent a Serious Threat to Health or Safety
We may use and disclose your health information with others, when necessary, to prevent a serious and imminent threat to your or another person’s health and safety. In such cases, we will only disclose your information with someone able to help prevent this threat.
We may disclose health information about you when authorized or required to do so by federal, Georgia, or local law or other judicial or administrative proceedings.
Military and Veterans
If you are a member of the armed forces, we may disclose your health information as required by military command authorities. We may also disclose health information about foreign military personnel to the appropriate foreign military authority.
We may disclose your health information for workers’ compensation or similar programs to the extent necessary to comply with the laws relating to workers’ compensation or other similar programs. These programs provide benefits for work- related injuries or illness.
Public Health Risks
We may disclose your health information for public health activities. These activities generally include the following:
Health Oversight Activities and Registries
We may disclose your health information to a health oversight agency for activities authorized by law and to patient registries for conditions such as tumor, trauma and burn. These oversight activities include audits, investigations, inspections and licensure surveys. These activities are necessary for the government to monitor health care systems, government programs, the outbreak of disease, and compliance with civil rights laws and to improve patient outcomes.
Lawsuits and Disputes
If you are involved in a lawsuit or a dispute, we may disclose your health information in response to a court or administrative order. We may also disclose your health information in response to a subpoena, discovery request or other lawful process, but only where a good faith effort has been made by the requesting party to provide you notice of the request and an opportunity to object to the request, or where the requesting party has made a reasonable effort to obtain a court or administrative order protecting health information.
We may disclose your health information if asked to do so by a law enforcement official:
Coroners, Health Examiners and Funeral Directors
We may disclose your health information to a coroner or health examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose health information about patients to funeral directors as necessary to carry out their duties.
National Security and Intelligence Activities
We may disclose your health information to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.
Protective Services for the President and Others
We may disclose your health information to authorized federal officials so that they may provide protection to the President, other authorized persons or foreign heads of state.
Inmates and Correctional Institutions
If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may disclose your health information to those authorities. This release would be necessary (1) for the institution to provide you with health care; (2) to protect the health and safety of you and others or (3) for the safety and security of the correctional institution.
Special Protections for HIV/AIDS, Alcohol and Substance Abuse, Mental Health and Genetic
Special privacy protections apply to HIV/AIDs-related information, alcohol and substance abuse information, mental health information, and genetic information. Some parts of this general Notice of Privacy Practices may not apply to these types of information. If your treatment involves this information, you may contact the Enterprise Privacy Officer for more information about these protections.
Other Uses and Disclosures of Health Information
Other uses and disclosures of your health information not covered by this Notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose your health information, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose your health information for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures we have already made with your permission and that we are required to retain our records of the care that we provided to you.
Incidental Health Disclosures
While we will take reasonable steps to safeguard the privacy of your health information, certain disclosures of your health information may occur. For example, during the course of a treatment session, other patients in the clinic area may see or overhear a discussion of your health information.
We reserve the right to revise this Notice. We reserve the right to make the revised Notice effective for health information we already have about you as well as any information we receive in the future. The revised Notice will contain the effective date. We will post a copy of the current Notice and any revised Notice in prominent locations throughout our facility and also on our website. You may request a copy of this Notice at any time.
If you want more information about our privacy practices or have questions or concerns, please contact us using the information listed at the end of this Notice.
If you believe your privacy rights have been violated, you may file a complaint with GRU College of Dental Medicine or with the Secretary of the U.S. Department of Health and Human Services. To file a complaint with GRU College of Dental Medicine, contact our Enterprise Privacy Officer using the information listed below. We will provide you with the contact information for the Secretary of the Department of Health and Human Services. We will not retaliate in any way if you choose to file a complaint with us or with the Department of Health and Human Services.
Our staff and students at the GRU College of Dental Medicine pledge to protect your private health information in accordance with current policies and laws.
As a patient, you have the right to:
We remain deeply committed to protecting your health information while still providing you with the best quality health care possible.
Requests for Forms or Inquiries Regarding this Notice Should Be Directed to:
Attn: Patient Advocate
Dental College of Georgia
1430 John Wesley Gilbert Drive
Augusta, GA 30912
Attn: Enterprise Privacy Officer
Augusta University Health
1120 15th Street
Augusta, GA 30912
Toll-free Hotline: (800) 576-6623