HIPAA Notice of Privacy Practices

Your Information. Your Rights. Our Responsibilities.

This notice describes how your dental/health information may be used and disclosed by Lehman & Menis Dental Implant and Oral Surgery Specialists and how you can get access to this information. Please review it carefully.

YOUR RIGHTS

You have certain rights pertaining to your health information. Your rights and some of our responsibilities are:

1. Obtain an electronic or paper copy of your dental record: You can ask to see or request an electronic or paper copy of your dental record and other health information we have about you. Ask us how to do this. Upon written request, we will provide a copy or summary of your dental/health information within a reasonable time.

   • If you ask to see or receive a copy of your record for purposes of reviewing current dental care, we may not charge you a fee.
   • If you request copies of your patient records of past dental care, or for certain appeals, we may charge you specified fees.
2. Request your dental record be amended or corrected:

   • You can ask us to correct dental/health information about you that you think is incorrect or incomplete. Ask us how to do this. We may say "no" to your request, but we'll tell you why in writing within 60 days.
3. Request us to contact you confidentially:

   • You can ask us to contact you in a specific way, for example, by home or office phone or by sending mail to a different address.
   • We will say "yes" to all reasonable requests.
4. Request us to limit what we use or share:

   • You can ask us not to use or share certain health information for treatment, payment, or our operations (TPO). We are not required to agree to your request, and we may say "no" if it would affect your care. Such requests should be made in writing.
   • If you pay for a service or dental/health care item out-of-pocket in full, you can ask us not to share that information, for the purpose of payment or our operations, with your dental/health insurer. We will say "yes" unless a law requires us to share that information.
5. Get a list of those with whom we've shared information:

   • You can ask for a list (an accounting) of the times we've shared your dental/health information during the previous six years from the date you ask, including who we shared it with and why. Such requests should be made in writing.
   • We will include all the disclosures except for those about treatment, payment, and dental care operations, and certain other disclosures such as any you asked us to make. We will provide one list/accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.
6. Get a copy of this privacy notice:

   • You can ask for a paper copy of this notice at any time and we will do so promptly, even if you agreed to receive it electronically.
7. File a complaint if you feel your rights are violated:

   • You can complain if you feel we have violated your rights by contacting our Privacy Officer using the contact information at the top of this page. We will not retaliate against you for filing a complaint.
   • You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to: 200 Independence Avenue, S. W., Washington, DC 20201, or calling 1-877-696-6775, or visiting the following website: www.hhs.gov/ocr/privacy/hipaa/complaints/ .

YOUR CHOICES

1. For certain health information, you can tell us your choices about what we share:

   • If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your written instructions. In these cases, you have both the right and choice to tell us NOT to:
     1. Share information with your family, close friends, or others involved in your care, such as your personal representative
     2. Share information in a disaster relief situation
     3. Include your information in a hospital directory
   • If you are not able to tell us your preference, for example if you were unconscious, we may share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.
2. Your authorization: If you provide an authorization in writing to permit other uses or disclosures of your dental/health information that are not described in the "Our Uses and Disclosures" section on the next page, you may revoke such authorization in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect.
3. Cases in which we will never share your information unless you give us written permission:

   • Marketing purposes; the sale of your information; most sharing of psychotherapy notes, and for most other sharing purposes.
4. Fundraising: We may contact you for fundraising efforts, but you can tell us not to contact you again.

OUR USES and DISCLOSURES

1. How we typically use or share your dental/health information: We need your consent before we disclose protected health information except in the following scenarios or the disclosure is for a medical emergency and we are unable to obtain your consent due to your condition or the nature of the medical emergency. We typically share your dental/health information in the following ways:

   • T = Treating You – We can share your health information with a provider in our Lehman & Menis Dental Implant and Oral Surgery Specialists network. We can use your dental/health information and share it with other professionals (such as other dentists, physicians or healthcare providers carrying out treatment we do not provide, pharmacists, medical or dental laboratory personnel) who are treating you. We may ask for your consent prior to disclosures for treatment. Example: A doctor treating you for an injury asks another doctor about your overall health condition.

     P = Payment/Billing – We can use and share your dental/health information to bill and get payment from health plans or other entities. We may ask for you consent prior to disclosures for payment. Example: We give information about you to your health insurance plan so it will pay for your services.

     O = Organizational Operations – We can use and share your dental/health information in connection with our healthcare operations to run our practice, improve your care, and contact you when necessary. We may ask for your consent prior to disclosures for organizational operations. Examples of healthcare operations can include: business planning, management and administrative services, quality assessment/improvement and licensing activities, evaluating our dental professionals and job performance activities, conducting training programs and education, as well as accreditation, certification, licensing or credentialing activities.

2. Other uses and disclosures for sharing your dental/health information: We are allowed or required to share your information in other ways that contribute to the public good, such as public health and research. We must meet many conditions in the law before sharing your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html

   1. Public health and safety: We can share dental/health information about you for certain public health and safety situations such as: preventing disease; helping with product recall; reporting adverse reactions to medications; reporting suspected abuse, neglect, or domestic violence; disaster relief efforts, and preventing or reducing a serious threat to anyone's health or safety.
   2. Research: We can use or share your information for health research if you don't object.
   3. To comply with the law: We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we are complying with federal privacy laws.
   4. Respond to organ and tissue donation requests: We can share health information about you with organ procurement organizations.
   5. Work with a medical examiner or coroner: We can share dental/health information with a coroner and medical examiner when an individual dies.
   6. Address workers' compensation, law enforcement, and other government requests: We can use or share dental/health information about you for worker's compensation claims, for law enforcement purposes or with a law enforcement official, unless required by law. We can also use or share dental/health information about you with health oversight agencies for activities authorized by law. Similarly, for special government functions such as military, national security, and presidential protective services.
   7. Respond to lawsuits and legal actions: We can share dental/health information about you in response to a court or administrative order, or in response to a subpoena. We will consult legal counsel upon receipt of such documents.
   8. Other State Law considerations: We are required to describe any state or other laws that require greater limits on disclosure. For example, we will not share any substance abuse, HIV/AIDS, or psychotherapy treatment records without your written permission.

OUR RESPONSIBILITIES

1. Maintain privacy & security: We are required by law to maintain the privacy & security of your protected health information.
2. Inform you if a breach occurs: We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
3. Follow notice practices: We must follow the duties and privacy practices described in this notice and give you a copy of it. We will not share your information other than described here unless you tell us we can in writing.

For more information: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html .

Effective Date & Changes To the Terms of This Notice – The effective date of this Notice of Privacy Practices is May 17, 2018 and will remain in effect until a revised version replaces it. We can change the terms of this notice and such changes will apply to all your information we have, including health information we created or received before any notice changes. Revised notices will be available upon request, in our office, and on our website.

Privacy Officer Contact Information:

Practice Manager
Lehman & Menis Dental Implant and Oral Surgery Specialists
850 Munshaw Ln
Crystal Lake, IL 60014
Phone: (815) 459-7400
Fax: (847) 658-9320