Gregory D Wilcox, DDS must collect timely and accurate health
information about you and make that information available to members of your
health care team in this agency, so that they can accurately diagnose your
condition and provide the care you need.
There may also be times when your health information will be sent to
service providers outside this agency for services that this agency cannot
provide. It is the legal duty of Gregory D Wilcox, DDS to protect your health information from
unauthorized use or disclosure while providing health care, obtaining payment
for that health care, and for other services relating to your health care.
describes how Gregory D Wilcox, DDS may use and disclose your protected health
information. This Notice also sets out the Agency’s legal obligations
concerning your protected health information and describes your rights to
control and access your health information under the Health Insurance
Portability and Accountability Act of 1996 (“HIPAA”), as amended by the Health
Information Technology for Economic and Clinical Health Act. This Notice has
been drafted in accordance with the HIPAA Privacy Rule, contained in the Code
of Federal Regulations at 45 CFR Parts 160 and 164. Terms not defined in this
Notice have the same meaning as they have in the HIPAA Privacy Rule.
review this document carefully and ask for clarification if you do not
understand any portion of it.
Gregory D Wilcox, DDS is required by law to maintain the privacy of
your protected health information and provide you with certain rights with
regard to your protected health information. It is obligated to provide you
with a copy of this Notice setting forth the Agency’s legal duties and its
privacy practices with respect to your protected health information. Gregory D Wilcox, DDS and any of its business associate must abide
by the terms of this Notice.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION
protected health information may be used and disclosed where it is necessary
for the purpose of providing health care services to you. Your protected health information may also be
used and disclosed to pay your health care bills and to support the operation
of your physician’s practice.
Business Associates. Gregory D Wilcox, DDS contracts with service providers – called
business associates – to perform various functions on its behalf. For example,
we may contract with a service provider to perform the administrative functions
necessary to pay your medical claims. To perform these functions or to provide
the services, business associates will receive, create, maintain, use, or
disclose protected health information, but only after Gregory Wilcox and the business associate agree in writing to
contract terms requiring the business associate to appropriately safeguard your
Gregory D Wilcox, DDS may use or disclose personal health information
in order to provide, coordinate, or manage your health care and related
services. This includes sharing your health information with other health care
providers, both within and outside this agency, regarding your treatment when
we need to coordinate and manage your health care. For example, we may share
your health information with doctors, nurses and other health care personnel
who are involved in providing your health care. Sharing health information can
be essential for your protection and quality care.
Gregory D Wilcox, DDS may use and give your health information to
other staff and health plans you designate to bill and collect payment for the
health care services received by you. We
may share information with your health plan to determine coverage status prior
to scheduled services. We will share
adequate information with departments that prepare bills and manage client
accounts in order to ensure payment for services rendered. We may share your health information with
agents of your insurance company or health plan to confirm services that were
provided to you.
Health Care Operations
Gregory D Wilcox, DDS may use or disclose, as needed, your protected
health information in order to support the business activities of our practice.
These “health care operations” allow us to improve the quality of care we
provide to you and our other clients and help us to reduce health care costs. Such
activities include, but are not limited to, quality assessment activities,
employee review activities, training of medical students, licensing, and
conducting or arranging for other business activities.
We may also
use or disclose your protected health information, as necessary, to provide you
with information about treatment alternatives or other health-related benefits
and services that may be of interest to you.
USES AND DISCLOSURES NOT REQUIRING
Gregory D Wilcox, DDS may use and/or disclose your health
information for those circumstances that have been determined by law to be so
important that your authorization may not be required. Prior to disclosing your health information,
we will evaluate each request to ensure that only necessary information will be
disclosed. Those circumstances include
disclosures that are:
Required by Law. We may use or disclose your protected
health information to the extent required by federal, state, or local law.
Public Health Activities. We may use or
disclose your protected health information for public health activities that
are permitted or required by law. For example, a disclosure may be made for the
purpose of preventing or controlling disease, injury or disability.
Health Oversight Activities. We may disclose protected health
information to health oversight agencies for purposes of legally authorized
health oversight activities, such as audits and investigations necessary for
oversight of the health care system and government benefit programs.
Lawsuits and Other Legal Proceedings. We may disclose
your protected health information in the course of any judicial or
administrative proceeding or in response to an order of a court or
administrative tribunal (to the extent such disclosure is expressly
authorized). If certain conditions are met, we may also disclose your protected
health information in response to a subpoena, a discovery request, or other
Abuse or Neglect. We may disclose your protected health
information to a government authority that is authorized by law to receive
reports of abuse, neglect, or domestic violence. Additionally, as required by
law, if we believe you have been a victim of abuse, neglect, or domestic violence,
it may disclose your protected health information to a governmental entity
authorized to receive such information.
Law Enforcement. Under certain conditions, we also may
disclose your protected health information to law enforcement officials for law
enforcement purposes such as responding to a court order; as necessary to
locate or identify a suspect, fugitive, material witness, or missing person; or
as relating to the victim of a crime.
Government Functions. An authorization is not required to use or disclose protected health
information for certain essential government functions. Such functions include:
assuring proper execution of a military mission, conducting intelligence and
national security activities that are authorized by law, providing protective
services to the President, making medical suitability determinations for U.S.
State Department employees, protecting the health and safety of inmates or
employees in a correctional institution, and determining eligibility for or
conducting enrollment in certain government benefit programs.
Workers’ Compensation. We may disclose your protected health information as
authorized by, and to comply with, workers’ compensation laws and other similar
programs providing benefits for work-related injuries or illnesses.
Others Involved in Your Health Care. We may disclose
your protected health information to a friend or family member that is involved
in your health care.
Relief. We also may disclose your information to an entity assisting
in a disaster relief effort so that your family can be notified about your
condition, status, and location. If you are not present or able to agree to
these disclosures of your protected health information, then, using
professional judgment, we may determine whether the disclosure is in your best
Coroner and Funeral
Directors. We may disclose protected health
information to funeral directors as needed, and to coroners or medical
examiners to identify a deceased person, determine the cause of death, and
perform other functions authorized by law.
Organ Donation. Cadaveric Organ, Eye, or Tissue Donation. We may use or disclose protected
health information to facilitate the donation and transplantation of cadaveric
organs, eyes, and tissue.
Disclosures to the Secretary of the U.S. Department
of Health and Human Services. We are required to disclose your
protected health information to the Secretary of the U.S. Department of Health
and Human Services when the Secretary is investigating or determining the Agency’s
compliance with the HIPAA Privacy Rule.
following is a description of your rights with respect to your protected health
Right to Inspect and Copy Your Protected Health Information. You have the
right to inspect and copy protected health information that may be used to make
decisions about your benefits. You must submit your request in writing. For
your convenience, you may request a form using the Contact Information at the
end of this Notice. Such requests will be fulfilled within 30 days where
possible. If you request copies, we may impose reasonable copy charges (which
may include a labor charge), as well as postage if you request copies be mailed
may also request that we disclose your
protected health information to an individual who has been designated by you as
your personal representative and who has qualified for such designation in
accordance with relevant law. Prior to such a disclosure, however, we must be
given written documentation that supports and establishes the basis for the
that under federal law, you may not inspect or copy the following records:
psychotherapy notes; information compiled in reasonable anticipation of, or use
in, a civil, criminal, or administrative action or proceeding; and protected
health information that is subject to law that prohibits access to protected
health information. Depending on the circumstances, a decision to deny access
may be reviewable. In some, but not all, circumstances, you may have a right to
have this decision reviewed.
Right to Request a
Restriction. You have the right to request that
Gregory D Wilcox, DDS restrict use or disclosure of protected health
information for treatment, payment or health care operations, disclosure to
persons involved in the individual’s health care or payment for health care, or
disclosure to notify family members or others about the individual’s general
condition, location, or death. We are under no obligation to agree to requests
for restrictions. In circumstances in which we do agree to a restriction, we
will comply with the agreed restrictions, except for purposes of treating you
in a medical emergency.
Non-Disclosure to Health Plan. A patient that pays in full for their services out of
pocket have the right to demand that the information regarding the service not
be disclosed to the patient’s third party payer since no claim is being made
against the third party payer.
Right to Request
Confidential Communications. You have the right to request an alternative means or location for
receiving communications of protected health information by means other than
those that Gregory D Wilcox, DDS typically employs. For example, you may
request that we communicate with you through a designated address or phone
number. Similarly, you may request that we send communications in a closed
envelope rather than a post card.
We will also accommodate
reasonable requests if you indicate that the disclosure of all or part of the
protected health information could endanger you. We will not question your
statement of endangerment. Any confidential communication request must be done
in writing and must explain how any payment will be handled.
Right to Request an
The Rule gives
individuals the right to have covered entities amend their protected health
information in a designated record set when that information is inaccurate or
incomplete. If we accept an amendment request, we will make reasonable efforts
to provide the amendment to persons that you identify as needing it and to
persons that we know might rely on the information to your detriment. If the
request is denied, we will provide you with a written denial and allow you to
submit a statement of disagreement for inclusion in the record. Furthermore we
will amend protected health information in our designated record set upon
receipt of notice to amend from another covered entity.
Right to Request an
You have a right
to an accounting of the disclosures of your protected health information by Gregory D Wilcox, DDS or any business associates with whom we do
business. The maximum disclosure accounting period is the six years immediately
preceding the accounting request, except we are not obligated to account for
any disclosure made before our Privacy Rule compliance date.
The Privacy Rule does not
require accounting for disclosures:
(a) for treatment, payment, or health care operations;
(b) to the individual or the individual’s personal
(c) for notification of or to persons involved in an
individual’s health care or payment for health care, for disaster relief, or
for facility directories;
(d) pursuant to an authorization;
(e) of a limited data set;
(f) for national security or intelligence purposes;
(g) to correctional institutions or law enforcement
officials for certain purposes regarding inmates or individuals in lawful
(h) incident to otherwise permitted or required uses or
disclosures to health oversight agencies and law enforcement officials must be
temporarily suspended on their written representation that an accounting would
likely impede their activities.
Right to Opt out of Fundraising Communications. You have the
right to opt out of any fundraising communications that eminent from (Agency Name) or any business associates with whom we do business. Treatment or
payments are not conditioned upon whether or not you choose to receive or opt
out of such communications. If at any time you wish to opt back in to
fundraising communication, you may do so. To elect or change your fundraising
communication preferences, please contact the appropriate person using the
Contact Information at the end of this Notice.
Right to be Notified of a Breach. You have the right
to be notified in the event that (Agency Name) or any business associates with
whom we do business discovers a breach of unsecured protected health
Right to a Paper Copy of This Notice. You have the
right to a paper copy of this Notice, even if you have agreed to accept this
Notice electronically. To obtain such a copy, please contact the appropriate
person using the Contact Information at the end of this Notice.
believe your privacy rights have been violated by us, or if you want to
complain to us about our privacy practices, you may contact our agency Privacy
Official. We will not penalize or in any way retaliate against individuals for
filing a complaint. All complaints should be submitted in writing to:
Gregory D Wilcox, DDS
2079 Anderson Rd. Suite A
Davis, CA 95616
also send a written complaint to the United States Secretary of the Department
of Health and Human Services.
Notice of Privacy Practices is effective January 1, 2013.
exercise any of the rights described in this Notice, for more information, or
to file a complaint, please contact Gregory
D Wilcox, DDS at 530-758-8120
or mail communications to:
2079 Anderson Rd.
Davis, CA 95616