This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Ultra Endodontics’ Commitment to Your Privacy
Ultra Endodontics is dedicated to maintaining the privacy of your protected health information (‘PHI’). PHI is information about you that may be used to identify you (such as your name, social security number or address), and that relates to (a) your past, present or future physical or mental health or condition, (b) the provision of healthcare to you, or (c) your past, present, or future payment for the provision of healthcare. In conducting its business, Ultra Endodontics will receive and create records containing your PHI. Ultra Endodontics is required by law to maintain the privacy of your PHI and to provide you with notice of its legal duties and privacy practices with respect to your PHI.
Ultra Endodontics must abide by the terms of this Notice while it is in effect. This current Notice takes effect on October 20, 2020, and will remain in effect until Ultra Endodontics replaces it. Ultra Endodontics reserves the right to change the terms of this Notice at any time, as long as the changes are in compliance with applicable law. If Ultra Endodontics changes the terms of this Notice, the new terms will apply to all PHI that it maintains, including PHI that was created or received before such changes were made. If Ultra Endodontics changes this Notice, it will post the new Notice on its Website and will make the new Notice available upon request.
Uses and Disclosures of PHI
Ultra Endodontics may use and disclose your PHI in the following ways:
- Treatment, Payment and Healthcare Operations. Ultra Endodontics is permitted to use and disclose your PHI for purposes of (a) treatment, (b) payment and (c) healthcare operations. For example:
- Treatment. Ultra Endodontics may disclose your PHI to another dentist or healthcare provider for purposes of continuity of care or in connection with the provision of follow-up treatment.
- Payment. Ultra Endodontics may use and disclose your PHI to your dental insurer or health plan in connection with the processing and payment of claims and other charges.
- Healthcare Operations. Ultra Endodontics may use and disclose your PHI in connection with its healthcare operations, such as providing customer services and conducting quality review assessments. Ultra Endodontics may engage third parties to provide various services for Ultra Endodontics. If any such third party must have access to your PHI in order to perform its services, Ultra Endodontics will require that third party to enter an agreement that binds the third party to the use and disclosure restrictions outlined in this Notice.
- Authorization. Ultra Endodontics is permitted to use and disclose your PHI upon your written authorization, to the extent such use or disclosure is consistent with your authorization. You may revoke any such authorization at any time. To un-authorize Ultra Endodontics to disclose your PHI to a third party, download the HIPAA Authorization to Disclose Protected Health Information here and mail it to the address listed on the form.
- As Required by Law. Ultra Endodontics may use and disclose your PHI to the extent required by law.
The following categories describe unique circumstances in which Ultra Endodontics may use or disclose your PHI:
- Public Health Activities. Ultra Endodontics may disclose your PHI to public health authorities or other governmental authorities for purposes including preventing and controlling disease, reporting child abuse or neglect, reporting domestic violence and reporting to the Food and Drug Administration regarding the quality, safety and effectiveness of a regulated product or activity. Ultra Endodontics may, in certain circumstances disclose PHI to persons who have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition.
- Workers’ Compensation. Ultra Endodontics may disclose your PHI as authorized by, and to the extent necessary to comply with, workers’ compensation programs and other similar programs relating to work-related illnesses or injuries.
- Health Oversight Activities. Ultra Endodontics may disclose your PHI to a health oversight agency for authorized activities such as audits, investigations, inspections, licensing and disciplinary actions relating to the healthcare system or government benefit programs.
- Judicial and Administrative Proceedings. Ultra Endodontics may disclose your PHI, in certain circumstances, as permitted by applicable law, in response to an order from a court or administrative agency, or in response to a subpoena or discovery request.
- Law Enforcement. Ultra Endodontics may, under certain circumstances, disclose your PHI to a law enforcement official, such as for purposes of identifying or locating a suspect, fugitive, material witness or missing person.
- Decedents. Ultra Endodontics may, under certain circumstances, disclose PHI to coroners, medical examiners and funeral directors for purposes such as identification, determining the cause of death and fulfilling duties relating to decedents.
- Research. Ultra Endodontics may, under certain circumstances, use or disclose PHI that is necessary for research purposes.
- Threat to Health or Safety. Ultra Endodontics may, under certain circumstances, use or disclose PHI if necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.
- Specialized Government Functions. Ultra Endodontics, may in certain situations, use and disclose PHI of persons who are, or were, in the Armed Forces for purposes such as ensuring proper execution of a military mission or determining entitlement to benefits. Ultra Endodontics may also disclose PHI to federal officials for intelligence and national security purposes.
Your Rights Regarding Your PHI
You have the following rights regarding the PHI maintained by Ultra Endodontics:
- Confidential Communication. You have the right to receive confidential communications of your PHI. You may request that Ultra Endodontics communicate with you through alternate means or at an alternate location, and Ultra Endodontics will accommodate your reasonable requests. You must submit your request in writing to Ultra Endodontics. To submit such a request, download the Request for Restricts Request Form here and mail it to the address listed on the form.
- Restrictions. You have the right to request restrictions on certain uses and disclosures of PHI for treatment, payment or healthcare operations. You also have the right to request that Ultra Endodontics restrict its disclosures of PHI to only certain individuals involved in your care or the payment of your care. You must submit your request in writing to Ultra Endodontics. Ultra Endodontics is not required to comply with your request. However, if Ultra Endodontics agrees to comply with your request, it will be bound by such agreement, except when otherwise required by law or in the event of an emergency. To submit such a request, download the Request for Restricts Request Form here and mail it to the address listed on the form.
- Inspection and Copies. You have the right to inspect and copy your PHI. You must submit your request in writing to Ultra Endodontics. Ultra Endodontics may impose a fee for the costs of copying, mailing, labor and supplies associated with your request. Ultra Endodontics may deny your request to inspect and/or copy your PHI in certain limited circumstances. If that occurs, Ultra Endodontics will inform you of the reason for the denial, and you may request a review of the denial. To request access to your PHI that is not already accessible to you in the TDO Portal, download the Request to Access PHI Form here and mail it to the address listed on the form.
- Amendment. You have a right to request that Ultra Endodontics amend your PHI if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is maintained by Ultra Endodontics. You must submit your request in writing to Ultra Endodontics and provide a reason to support the requested amendment. Ultra Endodontics may, under certain circumstances, deny your request by sending you a written notice of denial. If Ultra Endodontics denies your request, you will be permitted to submit a statement of disagreement for inclusion in your records. To make a request to amend PHI that you cannot otherwise change yourself through the Member Portal, download the Request to Amend PHI form here and mail it to the address listed on the form.
- Accounting of Disclosures. You have a right to receive an accounting of all disclosures Ultra Endodontics has made of your PHI. However, that right does not include disclosures made for treatment, payment or healthcare operations, disclosures made to you about your treatment, disclosures made pursuant to an authorization, and certain other disclosures. You must submit your request in writing to Ultra Endodontics and you must specify the time period involved (which must be for a period of time less than six years from the date of the disclosure). Your first accounting will be free of charge. However, Ultra Endodontics may charge you for the costs involved in fulfilling any additional request made within a period of 12 months. Ultra Endodontics will inform you of such costs in advance, so that you may withdraw or modify your request to save costs. To make a request for an accounting of disclosures, download the Request for an Account of Disclosures Form here and mail it to the address listed on the form.
- Breach Notification. You have the right to be notified in the event that Ultra Endodontics (or an Ultra Endodontics Business Associate) discovers a breach of unsecured PHI.
- Paper Copy. You have the right to obtain a paper copy of this Notice from Ultra Endodontics at any time upon request. To obtain a paper copy of this notice, please contact the Privacy Officer by writing to: Privacy Officer, Ultra Endodontics, 1769 Jamestown Rd., Suite 2B, Williamsburg, VA 23185 or sending an email to email@example.com.
- Complaint. You may complain to Ultra Endodontics and to the Secretary of the Department of Health and Human Services if you believe that your privacy rights have been violated. To file a complaint with Ultra Endodontics, you must submit a statement in writing to: Privacy Officer, Ultra Endodontics, 1769 Jamestown Rd., Suite 2B, Williamsburg, VA 23185 or sending an email to firstname.lastname@example.org. Ultra Endodontics will not retaliate against you for filing a complaint.
- Further Information. If you would like more information about your privacy rights, please send an email to the Privacy Officer at email@example.com.