NOTICE OF PRIVACY PRACTICES

NOTICE OF PRIVACY PRACTICES

1.  K. Alex Poole, II, DMD, PA may use and disclose protected health information for treatment, payment, and healthcare operations. Examples of these include, but are not limited to, requested preschool or sports physicals, foster care homes, home health agencies, and/or referral to other providers for treatment. Payment examples include, but are not limited to, insurance companies for claims including coordination of benefits with other insurers, and/or collection agencies. healthcare operations include, but are not limited to, internal quality control and assurance, including auditing of records.

2.  K. Alex Poole, II, DMD, PA is permitted or required to use or disclose protected health information without the individual's written consent or authorization in certain circumstances. Two examples of such are for public health requirements or court orders.

3.  K. Alex Poole, II,  DMD, PA will not use or disclose PHI for marketing purposes and/or disclosures constituting a sale of PHI without the individual's authorization.

4.  K. Alex Poole, II, DMD, PA will not sell or make any other use or disclosure of a patient's protected health information without the patient's written authorization. Such authorization may be revoked at any time. Revocation must be requested in writing.

5.  K. Alex Poole, II, DMD, PA will abide by the terms of this notice currently in effect at the time of the disclosure.

6.  K. Alex Poole, II, DMD, PA reserves the right to change the terms of this notice and to make new notice provisions effective for all protected information that it maintains. K. Alex Poole, II, DMD, PA will provide each patient with a copy of any new revisions of its Notice of Information Practices at the time of the patient's next visit, or the patient's last known address if there is a need to use or disclose any protected health information of the patient. Copies may also be obtained at any time at the office of K. Alex Poole, II, DMD, PA.

7.  Any patient, guardian or personal representative has the right to object to the use of their health information for directory purpose.

8.  Any patient, guardian or personal representative has the right to inspect and obtain copies of the patient's medical record. The records will be provided within 30 days of the request, and a reasonable charge may be assessed for any copies after the first request in a 12-month period. If K. Alex Poole, II, DMD, PA is unable to act within the required period, K. Alex Poole, II, DMD, PA may provide the patient with written notice of the reason for delay and expected date of completion of the request. This extension of time will not exceed 30 days.

9.  Any patient, guardian or personal representative has the right to request amendments be made to the patient's medical record.

10.  Any patient, guardian or personal representative has the right to request a 6-year accounting of all disclosures of the patient's medical record. The history will be provided within 30 days of the request, and a reasonable charge may be assessed for any copies after the first request in a 12-month period. If K. Alex Poole, II, DMD, PA is unable to act within the required period, K. Alex Poole, II, DMD, PA may provide the patient with written notice the reason for delay and the expected date of completion of the request. This extension of time will not exceed 30 days.

11.  Any patient, guardian or representative has the right to request restrictions as to how the patient's health information may be used or disclosed to carry out treatment, payment, or healthcare operations. K. Alex Poole, II, DMD, PA is not required to agree to the restrictions requested, but if K. Alex Poole, II, DMD, PA does agree, K. Alex Poole, II, DMD, PA must abide by those restrictions.

12.  Any patient, guardian or representative has the right to restrict disclosure of certain Personal Health Information to a health plan for payment or health care operation purposes, but not for treatment purpose, for items or services that have been paid in full and out-of-pocket.

13.  Any affected patient will be notified by the K. Alex Poole, II, DMD, PA Security Officer following a breach of unsecured Personal Health Information of the affected patient. The Practice has permission to contact me via e-mail.

14.  Any person/patient may file a complaint to K. Alex Poole, II, DMD, PA and to the U.S. Secretary of Health and Human Services if the patient believes his or her privacy rights have been violated. To file a complaint with the Practice, please contact the Privacy Officer at K. Alex Poole, II, DMD, PA, Attention: Privacy Officer, 2835 Horse Pen Creek Road, Suit 106, Greensboro, NC 27410; telephone (336)662-0807. All complaints will be addressed, and the results will be reported to the Privacy Officer.

15.  It is the policy of K. Alex Poole, II, DMD, PA that no retaliatory action will be made against any individual who submits or conveys a complaint of suspected or actual non-compliance of the privacy standards.


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