Privacy Practices

---

•

"'Y

, :(Jl:lf£alp .f",,~ily .Dantistry ~f.--:::~_

,

,':

:'~:;.:;:

+

"r

-

,;,.~::

:7: ::'" :,")'"'''~'

.~.

"

Buf€alo, MN .S53 13 'rr6;3) ~6'82-453'4 ' .

0

':,

';7763 '.

~E

N{S~'I,e:~p,grf.l~~PR4;VAQ¥c:_A .• e.~liGES",", .. ,.THISNOTICE~D,ESCRIBES;H~\y:HI¥.ALTI,jJNFQfJ,PJlATIOtii ABOl,lT X9lJ M~!BE U~~Q .AN[), DISCLOSED AND HOW YOU CAN GET ACCESS TO THISINFORMATIO,,.,..•. '--t..;'

,..'.,.'

-::'.'. ;, ;PLE~~E REMIEvv.rr:'.:~:AR~~Q.LLY; ;< ",,' 'T.HeE ,PRIVACY QF.YOt!,lR'HEALl1H INFqJI:M~TlqNJSIMPQr;p~Ar'fT.T9,

q~J(i~Ii~_A~'DltrY. '"

"',

<,' .. ,', ,''''''

',',"" " " ;.~.~, ,;,,'

"

US.;

c

, "".,

'

l/1.e,arerequJi:ed'b,y:applicatil~J(;}:cre(al and ,stat~.Iav(,!o 'l1'l~inf!iiiMItEi";Riiyacipf.y.Qorh~altfi":inf~im~tion:We 'arealso

ro~~1i~~~AQ:~ly~' you,m!s,N:QtlcJi;~~?~L~~KP:1~~~Y~Ji~~~iq~~t?~~]~~~!:~~M~\~'.~n~.~~a,C~~~~s ,(:~h?eihi~g'yp~r:tiealt~,

l(lt~I1T:!~JI~.(I,;We l'!lu~tf
,<:_

!::;v

~~~"'/'

~

y;'I,

>~

In

:-, ~ _,::

"I,

'~

'./.<..

~

,

''"

rf~:;.y.

We 'rest;lr'vetKeright~19change"oorprivacijipractic'ElSiShdthe,t'Elti'11s.;'dt~this'Notice'atany:,tir:ne;:provid~d !Such,cliang-es are p~!ii1iittEld, by applicable law. We reserve the righUo make the changesincour privacy practices and the new teims ·,orOtiji;Notice,'effe'~tiyeAorall"'i'Elalth':inforlTiali.on~tMt we,maintain, includin:gO.ealthil'lfermation we create9 or rece~ved before'wetm~dethe.:cl:ianges.,~efore:we;make'a sj§!'IitiG§lnt,chang~inourj;)iv~cY'p!actice~; we will.cha'nge'thl~NotiGe a,nemakethe new Notice avallableupcnrequest, '! ' '";, ' , "'0

,CO"

You m!ly.'r~qoesta 'copy ofour: Notice at~~yiirrte:;P:'or!mdr~j-it'1f6rrha:tiCi'n .'abouf':6i:ir;pfivacy.practice~;Otfor adeitional cople$ of this Notlqg, please contact us'using the.iljf6rl11ationlistedat.fhe endot this Notice. ;)

.-./

>'.'.'.

'". '/

',."., .•... y<

,

'

;USESCA'~:DDIS6Lo§URES'bFIiEALTH7:iNF&~MATI6N: , , We use'and dlsclose.health lntormatlonabout youtortreatment, payment, and healthcare operafions:Fbrexample: 'Tfeatment:We may -use or disclose yourhealth ihformatitm to' a physician or other healthcare provider'providiJ;lg treatment-to-you. ..' . ,'<--c,/

'

',"',,< ,"

' , ,,

','

,,'-':,,;

:-' .'.' ",'

' ' :'.'

,;"

';','

,payn"fent:'We may use and disclose your health informationto obtain'payment tor.services we prqVideyou., .. ,'. .... .', ";. ... .~..

'"

,-.-

.

.'..,

Healtl1cateQpel'ations: We may use and .discleseyotuhealth information in connection. with our .healthcar'e · 0~Ejfatioils;f'ieaifhcareqpen,itions Include quality assessment'and'iml'rovement activities; reviewing,.the,comfiletenee Of.qu~dificaHons6f,health'care 'pf6fessionals; 'evahJatihg:ptactititmet ,~rid':pr'ovider perlormaoce{ condueting t(aining programs.nccreditatlon, certification, licensinq.or credentialil19'activities. c

•

YOUr"A~th~;i%ation: In ~dditiont; our use o(your he~lthi'nforri.~ti0n for treatment, iayrl,enf or healtJlca~~:~p~~';~iidriS, yO!J.maygive us\'{rt~tenauthorization ~ouse your h~alth information or to disclose it to anyonef~ra:ny purpdse.)f yo~, glyeUS,an authOtizaf.ion,you may revoke i(jnwfitirigat a-nytime.,yourrevocation....,inootaffe8te':iy,~$~ ot'9.i~~,19sIilr~s pf:}rrTlittedby yqut,autbori?~1iOnwhileit .'Alasin effect lJnlassyougive. usa written"authotiZ:ation',We.cimnot:usedesqripe,q)n.the Patielj,tPijghts 's.ectionof tnis,Notice,We rnay discloSe:y.burhealth,irlf.Or:l'T:1..~tjol;ltQ~3lqmUy;;(rtE:lrnber, frieh~10r,o~h.:er"p,~rs.o!l,to tl:i~"efde:l1t neC'e$S~I¥',tcVl:relp~~th,yot.lr. ha~ltI!lC,~re. or.with:p?y,tn;ent~f0r;)iourlie.aJ~~ca,t~, 'bLJtoplyit yo~~~g~ee;;tfial rna.Ydo,s:o.

w,~

"B~r~p,~~IQ}l~~¥~.9In ,Care: wefrl~yu~e .O(9iicr6~e,healthinf?rlTl~tio;~~~,n~ti(i,th~-rpersonresportsil:lle:forY0ar ,c~re,o(your location, your general;fondition, or death.•,Jf,yotJare'preseht;'fl'i-en;:pridttouse ordisclosure of yotntieaith information, we will .provide YOIi'with an opportuJJiWto object to such uses or disclosures. In the event of your incapacItY,0rc:em~rgency circumstances, we Wilrdi$cl0S~;healfh' lntormatton.based ona/'€IeteJmin<:l~(jnusillg,our pretesslonal judgment disclosing 0nlyhealth,il'l,f~r.mation'thati$~direc::tly,;rel~vant" to.me .,p~rlSOtl:s 'inxolvementir;l',your heallhcare. We"WiII,alsouse our professional jjJQ9mentand our experiencewith commoh.practice to make reasonable inferences of your best interest in allowing a person to pick upfiUedpres~~ptions, rn.,edic,alsuppliEls, x-rays, or other similar'fbrmsofhealth lntorrnation. ' '.,' '".' ' , ' MarketIJlgtl~aJth·Related yourwrittenauthorization.

Sef.V.ices::We'~wilt,m6f usesyour he:allh,jIiJormationfor mar:ketingcOlllmupications Without ' . '

Required by LSw: We may use brClis6l6se Y:Q\Jr ~ealth:Iilfoimation when we are requirea by Jaw,to do 'so by law~ c

Abuse:orNeglect: We. may .disclese your healthil'lformati<)n,toapp'rop,ril!liesatithC:5iiti~s if,;we'rea~phably,believe "Wat you area possible victim of abuse, neglectjor domesfibviole!l~e or the possible victim of other crimes. We may dlsoloseyour health information to the extent necessaqr to!'lverta;seri.9.l,1f3Jbreatitas,your health;,or~~tetypr .the health or safetYof others. . ,. fc ~', {.;'~

John

C.

Stangl, D.D.S

,~"

':,-,.

, .." . .'

.."

-

. '"

···(·~:V~,;;;<;,;:~~;,:~~[,:~),:t~"::JN'., ,<'

National Security: We maydisclos~)9, m,ilitary ~,{Jth9mies;1~e,'he~Itf:(i~formatiOi'f of" ··ad ForeespersonneJ'urider certain.circumstances.WemaYdlsclps~';to;autfi&rlied.:f~~el'~l[qfflpi. '.' '.. .... .' ·"·uited·.tOr·laWful·intelligencEi; co~~teririt~((jgence, and other na~i9~l;tlf~~g""li,~~~~i,!iti~~;~~~m~~:i"'k'" , ....: ..... .... itutiono~.I~wE)r:ltotcement official havlnglawfulcustodY'ofprotected"healthmformatlon'of,inmate lent;u r certain circumstances.

or' .

~ppolntrne.~t R~!liJ~~~r~:yVe ~~y;,J~~fur·ai~ld~ey~ur;tl~a!{h~l~f~rffi~tibri;;t~;~;tovidgi{ojf'W\th;apPQintmetlt (suchasvolcemallmessages;·p.ostt:ards, or leHerS):" ...., .'.' .:~ =: '->"- _.'. f -.'~;:~_,>.;;. ,:'; ., '~-'::-<~':>.' <,:-~;i"-:·s:7~:;;.~_~~--:'.·"··;· .... -:;-. ~., ..,,'-.... "~7...;~" ~:>".:-:.:: .../';"

·r~;

0"':"'"

r

...."

reminders

"..

.

•••

PATIENTRIt3Ht~f;;;t

..'}.t:c:'.!<;::,c./,.;

.:'}i.

iT·>';,"':._

'.:;:

•. ;.<

Access: You haveth'er-i9~t.10.loOk atorge.tcopie~()f·.yo~ffle1:llth.infolTll~,tion, with:Umitedexgeptions.¥()Urriay request thst'l!eprovidElc()pies \haf()rmatQthert",~n;p'fldt'o'c6pie~;·:W~:iWiU'1U"s-ai;thefontlat. you. request unless we cannot practicably do so. (You must make iil'eqIiEfgf'ln"w~ting: too~taiti acc~SScf()'your'healtlii;iFlfoimation.You-may obtain a form to request access by using the conracfinformiiJi6rfliste-d allhe end of this Notice. We; ~i!lc~~[g~ ,Y9u a r.e.asonabl~\co~t~bas,e.d fee to.r eX(J'er.l~essu.?~ a$p.oRie~~~d.s,taff t,iI!lElo"Y6umay ~ISo requ~s~ acc~¥ byrs-eriBing us a I~tt~rto the ;,addre$S :Ci~the end. of, this Ndtic.e. Jf,Y6lJ;;f%iti~stc9.~i~S; 'We, wiUj~hat.ge'yOti$s.9:0'f~r: eac~~F~ge, $_._.._'_._.per h~urfoq>taff timeto Iqc,at~and,coRy~,}lQurh:e~lt~~iiif(ir:!flatio~i a:ndp'()s~age:1fyou watirth~c'op,ie$~mail~d to you, If you request an alternative form~t,we: will>cRa"Qti'~cQst;~ase~.fe:E!Jor .pr9vi~i6~YdiJrJJ~al{h0i~(ortnaUp~'jfnhat fOlmat.lfyou prefer, we wiUprepare a summary or aneX~I~fu"M'ii:My6ti'~' he·althinfbrm~tid~';(6r~'. f.~e,b6Mtad:q$,b§ihg the'informa'ti~n,listed;at theFer.lcj'9fthis.N0ticef.or·El'full~explanatjpn.:Qf:'gtllr4~~l>truptl;lre.)~,,·}.':··.·:t,':;,,-c;,Ji .',,." '.-,

.

,,!~:.. '..

~/ ../.:s.';: ..:

.:,;,.

:~',>'~r~;~: -:;~~~.,:j •.~:,.)\,--.:~~ ... t;~'~· .'::,,~-;,~: "i'· .

- .-,:./.

'Di'$'cIQsUl'e;,Accounting:You havethe;.riglifto":r~ceive,:a;'lists6f :i~stctI'i6~s'inMhith, we or •.QunbusimeS$asspciates dls:<::los'ediyoiJrhe·?lth-inform8.tion·forptrrp'C5sesi'oftler,}t[ian"tteatiflegtf:paYnieht,'healthcareo~etation's'and:;ceitaircofh~r:' activities, forthe last 6 years, but not before April 14; 200S;.Ifyou,request;tnis a6countiligrnc;jre'tharf.·oncein 'a'42-'rtlOnth 'pe,nqd, we may char,geyou:ar~asonable;rc~st-based Jee.,for rE:t$P9nding these addjtional requests, .,

-'.

-

l

_

.?

i<~:,-::,

.

.

.

.' _

.;,

',.,".~

...

-.

10

-',

,_:~~;}:,~:','.;<'\, ,·>{'.,;_<::.~_,:,:,~?:·(::/"":i",:T'<:;}'i:

-.,' ,-:. '<;,;',::~.~;

_.'

.:,::':','~;::'

,<--'::':_.-"",

_.

..~_..,

:'-:,

:;-' ',' -":~,;~~(;'.

.';.

"

,':

'

f\.,o,·-,,,: ,~,

,,',/',',":,i,:":,

.«. '.;

Restrlcti.on:. You. have the right torequesrtbat'Neplace 'l:idqitioru~rrestiibti(mS()n our use or di~¢losureof Your health inf6rma:tion, We are not required to agree to theseadditi6naJrestfig:ti6n.S,;l;tutif vie dO,.,We,WiU.<;I,bidebyoUta:gr~erner.lt (el(q~Rtj~!iIJ~m~rgenc'Y)~

....

"J~':»':;'::::~::/'__~;_:;;:~,.',•. :>iJ'::';;;':"l'o;'~;~~':\~'_:,';"!i:;~ '~,:C:','.

'., . .'0>'

....

Alter:na~lve1'Gommunicatioh: Youhave-the righttoti,e~(1lyesUhat:,w.~ I;:OrnmI;lQicate~ith.you .ab6u~ YQ",rf,h~alth lnfCi1I'iTfatlonbyaltemative rneansor to-altemative locatiOns. (You must-make your request.in Writing.)Your requ~~t;nll!st specify, alternative rneansor.IQCation,a~dprovide satisfabtoryexpla~ation how payments will be haocUed·under theaJ~:ernativeme~h'sc)rlocationy6i:i request'.... ...•. . ". i.,. .::.",'

:: ..'";,:

_.

•

,'_

.'

"::/

:;,

.~'

>";(_~.:'.:'~:

_. _.-:).\r:

.'

,_ _

_

. ~'..

;,J~' ~

_'~'::

....

4meodl'l1elit: You have me right to requestitha,twe~-ai.ner:td¥surbeal.~h,JJ;lformat!on~ (Y0'-:lrreq\J~,~tJllU~tpe,Jl11tllVr:itilig, 'a'ndit;mustexplaibwhy

the,informationshould,be,am!'iRdEld;),Wemaydeny,yourrequest -.

-.

•

-

-'.

tI,nder c:ertaincircurnstsnces. -.

-.

.

.

<-

-'.-

-.

"".

•

./

./

Ele~tronicNotice~ltyou thi~ Notiee in .writtenform.

receive this.Notice on ourWebSiteO;by'ei~ctronic . . . . C,':' .' ,. . -

..

mail"(e-ltiai.),. you 'are,:g~~itled t~'r~~eive . .....,

:".;

'c:.'"

.'

•

(}4~$t:ION~4~Ei.¢,OMPLAI~TS.-< ... '" i ...." If yOu want mote information' about our privacy ,ptact[~~s ;o{fia-.ie:questib~~::ol' conc~'rn~; .:»

-

.~.

•

•

.•

'

_

--.'

'.'

•.•..••.•

'- ,.....-

, ••

, •..••

. ':

..

;

-:'.

•.•

',,,,

•..•.•••..•..

'-

,',

-

;;"

.~' -r:,'

':<

.' ;./~::'~';;

. -'

•..••.•...•.•.

'-

_.

,

..

.

".,:,

•..•.

;;....··,r•.

,.'

.

'.'

••

.

,-;',i.

:".,.

P!~~~~' ctmtae:t!iis,"" ' .."

. -

:;.

'.".';,'_

.":

.. f

•

'lFyou Sl'e,:eohcemed:thaf.w9 may have-violated your Priv.(lpy:,right~;.or, you disagre'ewitha.,decisien we .made.about ~'cc~$~Ho youro'ealth inforrriatidn or inr~spoAse'toa'feqU9'st,you madeto:arii·end.dr/r~striGtthe~useor. diSclol>,ure of -: . yourh~al{h rn(6ifriati~h'6r t6'hciye:liJs •.C6mmuni~tewithV()l:I;bY';altem~tive"mea~s;,ot'at'-altem~tiveYIQG'atiorfs~ you may cO~P\~iXlto;(uS.;H~rO~~\~~:Btin~acti~fortJ;l~ti.o?.I,i~t~~i,~.th~.~p~.. :" tl;le l;J.S>.dD,ePM.rnet;lt:(jfHealth~nd:Hl:J.l!ilar.lS~: . .~Jt. the'U.S, Depad!iP~!JtQfl;ie~lthang:J:luQ)a!1,~~'~~w~oJ1reql;l: ,

We

. e. Y9~,~!.~0~ay,~~bmi~:,a,~~~~~ If~.rpP.!~!~Lt.0 '....I;i!headdress toJ,le:y,()qI9,ornpl~IIl~.\Vlth '. Y

,

"

$liPPort:,;~'~r ri~hMothepnyaCY1drcy~u~'ih~~~~i~i6~ation: We-;WiU,not;etalifite .cOm'jlllainlfwith us or' with .theV ..~. 'bepartrtlent±6f";Healtfrahc:l, Human'Services.· Contact Officer:' Telephone:

7,

JOhn c. siangl;liD~S.

,7$3"682-68.85

.: e.

•

•

I·

'0

",.:::>"

in any wayjf ¥6uchOds,~'t~ ..,.,

...

iil~ a '

Buffalo Family Dentistry -'

,Ce/J7L£v.

I()& "

(763) 682-6885

Dr.

Buffalo

, MN 55313

Fax: (763) 682-4534

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES * You May Refuse to Sign This Acknowledgement

I, office's Notice of Privacy Practices.

--,

have

*

received

a copy

of this

Please Print Name

Signature

Date

For Office Use Only

We attempted to obtain written acknowledgement of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

o o o o

Individual refused to sign Communications

barriers prohibited obtaining the acknowledgement

An emergency situation prevented us from obtained acknowledgement Other (Please Specify)

John C. Stangl, D.D.S