Tim Kelly DDS, DBA Rushmore Dental
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
AND
REVIEW IT CAREFULLY.
We are required by law to maintain the privacy of protected health information, to
provide individuals with notice of our legal duties and privacy practices with
respect to protected health information, and to notify affected individuals following
a breach of unsecured protected health information. We must follow the privacy
practices that are described in this Notice while it is in effect. This Notice takes effect
04/06/2016, and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this Notice at
any time, provided such changes are permitted by applicable law, and to make new
Notice provisions effective for all protected health information that we maintain.
When we make a significant change in our privacy practices, we will change this
Notice and post the new Notice clearly and prominently at our practice location, and
we will provide copies of the new Notice upon request.
You may request a copy of our Notice at any time. For more information about our
privacy practices, or for additional copies of this Notice, please contact us using the
information listed at the end of this Notice.
___________________________________________________________________
HOW WE MAY USE AND DISCLOSE HEALTH INFORMATION ABOUT YOU
We may use and disclose your health information for different purposes, including
treatment, payment, and health care operations. For each of these categories, we
have provided a description and an example. Some information, such as HIV-related
information, genetic information, alcohol and/or substance abuse records, and
mental health records may be entitled to special confidentiality protections under
applicable state or federal law. We will abide by these special protections as they
pertain to applicable cases involving these types of records.
Treatment. We may use and disclose your health information for your treatment.
For example, we may disclose your health information to a specialist providing
Payment. We may use and disclose your health information to obtain
reimbursement for the treatment and services you receive from us or another entity
involved with your care. Payment activities include billing, collections, claims
management, and determinations of eligibility and coverage to obtain payment from
you, an insurance company, or another third party. For example, we may send
claims to your dental health plan containing certain health information.
Healthcare Operations. We may use and disclose your health information in
connection with our healthcare operations. For example, healthcare operations
include quality assessment and improvement activities, conducting training
programs, and licensing activities.
Individuals Involved in Your Care or Payment for Your Care. We may disclose
your health information to your family or friends or any other individual identified
by you when they are involved in your care or in the payment for your care.
Additionally, we may disclose information about you to a patient representative. If a
person has the authority by law to make health care decisions for you, we will treat
that patient representative the same way we would treat you with respect to your
Disaster Relief. We may use or disclose your health information to assist in disaster
Required by Law. We may use or disclose your health information when we are
required to do so by law.
Public Health Activities. We may disclose your health information for public health
activities, including disclosures to:
o Prevent or control disease, injury or disability;
o Report child abuse or neglect;
o Report reactions to medications or problems with products or
o Notify a person of a recall, repair, or replacement of products or
o Notify a person who may have been exposed to a disease or condition;
o Notify the appropriate government authority if we believe a patient
has been the victim of abuse, neglect, or domestic violence.
National Security. We may disclose to military authorities the health information of
Armed Forces personnel under certain circumstances. We may disclose to
authorized federal officials health information required for lawful intelligence,
counterintelligence, and other national security activities. We may disclose to
correctional institution or law enforcement official having lawful custody the
protected health information of an inmate or patient.
Secretary of HHS. We will disclose your health information to the Secretary of the
U.S. Department of Health and Human Services when required to investigate or
determine compliance with HIPAA.
Worker’s Compensation. We may disclose your PHI to the extent authorized by
and to the extent necessary to comply with laws relating to worker’s compensation
or other similar programs established by law.
Law Enforcement. We may disclose your PHI for law enforcement purposes as
permitted by HIPAA, as required by law, or in response to a subpoena or court
Health Oversight Activities. We may disclose your PHI to an oversight agency for
activities authorized by law. These oversight activities include audits, investigations,
inspections, and credentialing, as necessary for licensure and for the government to
monitor the health care system, government programs, and compliance with civil
Judicial and Administrative Proceedings. If you are involved in a lawsuit or a
dispute, we may disclose your PHI in response to a court or administrative order.
We may also disclose health information about you in response to a subpoena,
discovery request, or other lawful process instituted by someone else involved in
the dispute, but only if efforts have been made, either by the requesting party or us,
to tell you about the request or to obtain an order protecting the information
Research. We may disclose your PHI to researchers when their research has been
approved by an institutional review board or privacy board that has reviewed the
research proposal and established protocols to ensure the privacy of your
Coroners, Medical Examiners, and Funeral Directors. We may release your PHI
to a coroner or medical examiner. This may be necessary, for example, to identify a
deceased person or determine the cause of death. We may also disclose PHI to
funeral directors consistent with applicable law to enable them to carry out their
Fundraising. We may contact you to provide you with information about our
sponsored activities, including fundraising programs, as permitted by applicable
law. If you do not wish to receive such information from us, you may opt out of
receiving the communications.
Other Uses and Disclosures of PHI
Your authorization is required, with a few exceptions, for disclosure of
psychotherapy notes, use or disclosure of PHI for marketing, and for the sale of PHI.
We will also obtain your written authorization before using or disclosing your PHI
for purposes other than those provided for in this Notice (or as otherwise permitted
or required by law). You may revoke an authorization in writing at any time. Upon
receipt of the written revocation, we will stop using or disclosing your PHI, except to
the extent that we have already taken action in reliance on the authorization.
Your Health Information Rights
Access. You have the right to look at or get copies of your health information, with
limited exceptions. You must make the request in writing. You may obtain a form to
request access by using the contact information listed at the end of this Notice. You
may also request access by sending us a letter to the address at the end of this
Notice. If you request information that we maintain on paper, we may provide
photocopies. If you request information that we maintain electronically, you have
the right to an electronic copy. We will use the form and format you request if
readily producible. We will charge you a reasonable cost-based fee for the cost of
supplies and labor of copying, and for postage if you want copies mailed to you.
Contact us using the information listed at the end of this Notice for an explanation of
If you are denied a request for access, you have the right to have the denial reviewed
in accordance with the requirements of applicable law.
Disclosure Accounting. With the exception of certain disclosures, you have the
right to receive an accounting of disclosures of your health information in
accordance with applicable laws and regulations. To request an accounting of
disclosures of your health information, you must submit your request in writing to
the Privacy Official. If you request this accounting more than once in a 12-month
period, we may charge you a reasonable, cost-based fee for responding to the
Right to Request a Restriction. You have the right to request additional
restrictions on our use or disclosure of your PHI by submitting a written request to
the Privacy Official. Your written request must include (1) what information you
want to limit, (2) whether you want to limit our use, disclosure or both, and (3) to
whom you want the limits to apply. We are not required to agree to your request
except in the case where the disclosure is to a health plan for purposes of carrying
out payment or health care operations, and the information pertains solely to a
health care item or service for which you, or a person on your behalf (other than the
health plan), has paid our practice in full.
Alternative Communication. You have the right to request that we communicate
with you about your health information by alternative means or at alternative
locations. You must make your request in writing. Your request must specify the
alternative means or location, and provide satisfactory explanation of how
payments will be handled under the alternative means or location you request. We
will accommodate all reasonable requests. However, if we are unable to contact you
using the ways or locations you have requested we may contact you using the
information we have.
Amendment. You have the right to request that we amend your health information.
Your request must be in writing, and it must explain why the information should be
amended. We may deny your request under certain circumstances. If we agree to
your request, we will amend your record(s) and notify you of such. If we deny your
request for an amendment, we will provide you with a written explanation of why
we denied it and explain your rights.
Right to Notification of a Breach. You will receive notifications of breaches of your
unsecured protected health information as required by law.
Electronic Notice. You may receive a paper copy of this Notice upon request, even if
you have agreed to receive this Notice electronically on our Web site or by
electronic mail (e-mail).
Questions and Complaints
If you want more information about our privacy practices or have questions or
concerns, please contact us.
If you are concerned that we may have violated your privacy rights, or if you
disagree with a decision we made about access to your health information or in
response to a request you made to amend or restrict the use or disclosure of your
health information or to have us communicate with you by alternative means or at
alternative locations, you may complain to us using the contact information listed at
the end of this Notice. You also may submit a written complaint to the U.S.
Department of Health and Human Services. We will provide you with the address to
file your complaint with the U.S. Department of Health and Human Services upon
We support your right to the privacy of your health information. We will not
retaliate in any way if you choose to file a complaint with us or with the U.S.
Department of Health and Human Services.
Our Privacy Official: Tim Kelly
Telephone: 605-593-0037 Fax: 605-593-8351
Address: 1600 Mountain View Rd., Suite 104; Rapid City, SD 57702
E-mail: [email protected]
Reproduction of this material by dentists and their staff is permitted. Any other use, duplication or distribution by any other
party requires the prior written approval of the American Dental Association. This material is educational only, does not
constitute legal advice, and covers only federal, not state, law. Changes in applicable laws or regulations may require
revision. Dentists should contact their personal attorneys for legal advice pertaining to HIPAA compliance, the
HITECH Act, and the U.S. Department of Health and Human Services rules and regulations.
© 2016 American Dental Association. All Rights Reserved.
