Dr. Thomas A. Dawson - Privacy Policy Statement

1. OUR COMMITMENT TO YOUR PRIVACY
The privacy of your health care information is important to us. We understand that your health care information is personal and we are committed to protecting it. In conducting our business, we will create records regarding you and the treatment and services we provide to you. We need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and share health care information about you. We also describe your rights and certain duties we have regarding the use and disclosure of health care information.

2. OUR LEGAL DUTY

Law Requires Us To:

A. Keep your health care information private.
B. Give you this notice describing our legal duties, privacy practices, and your rights regarding your health care information.
C. Follow the terms of the notice that is now in effect.

We Have the Right To:

A. Change our privacy practices and the terms of this notice at any time, provided that the changes are permitted by law.
B. Make the changes in our privacy practices and the new terms of our notice effective for all medical information that we keep, including information previously created or received before the changes.

Notice of Change to Privacy Priorities:

A. Before we make an important change in our privacy practices, we will change this notice and make the new notice available upon request.

3. WE MAY USE AND DISCLOSE YOUR HEALTH CARE INFORMATION IN THE FOLLOWING WAYS
The following categories describe the different ways in which we may use and disclose your health care information. Not every use or disclosure will be listed. However, we have listed all of the different ways we are permitted to use and disclose health care information. We will not use or disclose your health care information for any purpose not listed below without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to us.

For Treatment: We may use health care information about you to provide you with medical treatment or services. We may disclose health care information about you to doctors, nurses, technicians, medical students or other people who are taking care of you. We may also share health care information about you to your other health care providers to assist them in treating you. We may use and disclose your health care information to you to inform you of potential treatment options or alternatives.

For Payment: We may use and disclose your health care information for payment purposes.

For Health Care Operations: We may use and disclose your health care information for our health care operations. This might include measuring and improving quality, evaluating the performance of employees, conducting training programs, and getting accreditation, certificates, licenses and credentials we need to serve you.

Appointment Reminders: We may use and disclose your health care information to contact you and provide you with appointment reminders (such as voicemail messages, postcards, or letters).

Treatment Options: We may use and disclose your health care information to inform you of potential treatment options or alternatives.

Health-Related Benefits and Services: We may use and disclose your health care information to inform you of health-related benefits or services that may be of interest to you.

Release of Information to Family/Friends: We may release your health care information to a friend or family member that is involved in your care, or who assists in taking care of you. If you are present, we will get your permission if possible before we share, or give you the opportunity to refuse permission. In case of emergency, and if you are not able to give or refuse permission, we will share only the health information that is directly necessary for your health care, according to our professional judgment. We will also use our professional judgment to make decisions in your best interest about allowing someone to pick up health care information for you.

Disclosures Required by Law: We will use and disclose your health care information when we are required to do so by federal, state or local law.

4. ADDITIONAL USES AND DISCLOSURES
The following categories describe unique scenarios in which we may use or disclose your health care information.

Workers Compensation: We may disclose your health care information when authorized and necessary to comply with laws relating to workers compensation or other similar programs.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Court Orders and Judicial and Administrative Proceedings: We may use and disclose your health care information in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your health care information in response to a discovery request, subpoena, or other lawful process by another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an order protecting the information the party has requested.

Deceased Patients: We may release your health care information to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we may also release information in order for funeral directors to perform their jobs.

Serious Threats to Health or Safety: We may use and disclose your health care information when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a person or organization able to help prevent the threat.

Military: We may disclose your health care information if you are a member of U. S. or foreign military forces (including veterans) and if required by the appropriate authorities.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health care information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement officials having lawful custody of protected health information if you are an inmate or you are under the custody of a law enforcement official.

Health Oversight Activities: We may disclose health care information to an agency providing health oversight for oversight activities authorized by law, including audits, civil, administrative, or criminal investigations or proceedings, inspections, licensure or disciplinary actions, or other authorized activities.

5. YOUR RIGHTS REGARDING YOUR HEALTH CARE INFORMATION

You Have the Right To:

A. Confidential Communications. You have the right to request that we communicate with you about your health and related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home, rather than at work. In order to request a type of confidential communication, you must make a written request to our Privacy Official specifying the requested method of contact, or the location where you wish to be contacted. We will accommodate reasonable requests. You do not need to give a reason for your request.

B. Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your health care information for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your health care information to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your health care information, you must make your request in writing to our Privacy Official. Your request must describe in a clear and concise fashion:

(i) the information you wish restricted;
(ii) whether you are requesting to limit our practice's use, disclosure or both; and
(iii) to whom you want the limits to apply.

C. Inspection and Copies. You have the right to inspect and obtain a copy of the health care information that may be used to make decisions about you, including patient medical records and billing records. You must submit your request in writing to our Privacy Official in order to inspect and/or obtain a copy of your health care information. We may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. We may deny your request to inspect and/or copy in certain limited circumstances; however you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.

D. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, you request must be made in writing and submitted to our Privacy Official. You must provide us with a reason that supports your request for amendment. We will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion:

- accurate and complete;
- not part of the health care information kept by or for this medical practice
- not part of the health care information which you would be permitted to inspect and copy; or
- not created by this medical practice, unless the individual or entity that created the information is not available to amend the information.

E. Accounting of Disclosures. All of our patients have the right to request an "accounting of disclosures." An "accounting of disclosures" is a list of certain non-routine disclosures we have made of your health care information for non-treatment, nonpayment or non-operations purposes. Use of your health care information as part of the routine patient care our practice is not required to be documented. In order to obtain an "accounting of disclosures", you must submit your request in writing to our Privacy Official. All requests for an "accounting of disclosures" must state a time period which may not be longer than six (6) years from the date of disclosure and may not include dates before April 14, 2003. The first list you request within a 12-month period is free of charge, but we may charge you for additional lists within the same 12-month period. We will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.

F. Right to Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time. To obtain a paper copy of this notice, contact our Privacy Official.

G. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with us or the Secretary of the Department of Health and Human Services. To file a complaint with us, contact our Privacy Official. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

H. Right to Provide an Authorization for Other Uses and Disclosures. We will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your health care information may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your medical information for the reasons described in the authorization. Please note, we are required to retain records of your care.

We support your right to the privacy of your health information. If you want more information about our privacy practices, need applicable forms or have questions or concerns, please contact:

Julie Dawson, Privacy Official
Thomas A. Dawson, D.D.S., P.C.
508 M-55, Tawas City, Michigan 48763
Telephone: (989) 362-6186
E-mail: julie@drthomasadawson.com