JOHN L. LITTLE, D.D.S, P.A ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES -Yu I, Privacy Practices. May Refuse t Sign This Acknwledgement- ---, have received a cpy f this ffice's Ntice f {Please Print Name} {Signature} {Date} Fr Office Use Only We attempted t btain written acknwledgement f receipt f ur Ntice f Privacy Practices, but acknwledgement culd nt be btained because: Individual refused t sign Cmmunicatins barriers prhibited btaining the acknwledgement An emergency situatin prevented us frm btaining acknwledgement Other (Please Specify)
Updated Ntice f Privacy Practices THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US. Our Legal DUty We are required by applicable federal and state law t maintain the privacy f yur prtected health infrmatin. We are als required t give yu this Ntice abut ur privacy practices, ur legal duties, and yur rights cnceming yur prtected health infrmatin. We must fllw the privacy practices that are described in this Ntice while it is in effect. This Ntice takes effect 01/01/2010, and will remain in effect until we replace it. We reserve the right t change ur privacy practices and the terms f this Ntice at any time, prvided such changes are permitted by applicable law. We reserve the right t make the changes in ur privacy practices and the new terms f ur Ntice effective fr all health infrmatin that we maintain, including health infrmatin we created r received befre we made the changes. Befre we make a significant change in ur privacy practices, we will change this Ntice and prvide the new Ntice at ur practice lcatin, and we will distribute it upn request. Yu may request a cpy f ur Ntice at any time. Fr mre infrmatin abut ur privacy practices, r fr additinal cpies f this Ntice, please cntact us using the infrmatin listed at the end f this ntice. Yur Authrizatin: In additin t ur use f yur health infrmatin fr the fllowing purpses, yu may give us written authrizatin t use yur health infrmatin r t disclse it t anyne fr any purpse. If yu give us an authrizatin, yu may revke it in writing at any time. Yur revcatin will nt affect any use r disclsures permitted by yur authrizatin while it was in effect. Unless yu give us a written authrizatin, we cannt use r disclse yur health infrmatin fr any reasn except thse described in this Ntice. Uses and Disclsures f Health Infrmatin We use and disclse health infrmatin abut yu withut authrizatin fr the fllwing purpses. Treatment: We may use r disclse yur health infrmatin fr yur treatment. Fr example, we may disclse yur health infrmatin t a physician r ther healthcare prvider prviding treatment t yu. Payment: We may use and disclse yur health infrmatin t btain payment fr services we prvide t yu. Fr example, we may send claims t yur dental health plan cntaining certain health infrmatin. Healthcare Operatins: We may use and disclse yur health infrmatin in cnnectin with ur healthcare peratins. Fr example, healthcare peratins include quality assessment and imprvement activities, reviewing the cmpetence r qualificatins f healthcare prfessinals, evaluating practitiner and prvider perfrmance, cnducting training prgrams, accreditatin, certificatin, licensing r credentialing activities. T Yu Or Yur Persnal Representative: We must disclse yur health infrmatin t yu, as described in the Patient Rights sectin f this Ntice. We may disclse yur health infrmatin t yur persnal representative, but nly if yu agree that we may d s. Persns Invlved In Care: We may use r disclse health infrmatin t ntify, r assist in the ntificatin f (including identifying r lcating) a family member, yur persnal representative r anther persn respnsible fr yur care, f yur lcatin, yur general cnditin, r death. If yu are present, then prir t use r disclsure f yur health infrmatin, we will prvide yu with an pprtunity t bject t such uses r disclsures. In the event f yur absence r incapacity r in emergency circumstances, we will disclse health infrmatin based n a determinatin using ur prfessinal judgment disclsing nly health infrmatin that is directly relevant t the persn's invlvement in yur healthcare. We will als use ur prfessinal judgment and ur experience with cmmn practice t make reasnable inferences f yur best interest in allwing a persn t pick up filled prescriptins, medical supplies, x-rays, r ther similar frms f health infrmatin. Disaster Relief: We may use r disclse yur health infrmatin t assist in disaster relief effrts. Marketing Health-Related Services: We will nt use yur health infrmatin fr marketing cmmunicatins withut yur written authrizatin. Required by Law: We may use r disclse yur health infrmatin when we are required t d s by law. Public Health and Public Benefit We may use r disclse yur health infrmatin t reprt abuse, neglect, r dmestic vilence; t reprt disease, injury, and vital statistics; t reprt certain infrmatin t the Fd and Drug Administratin (FDA); t alert smene wh may be at risk f cntracting r spreading a disease; fr health versight activities; fr certain judicial and administrative prceedings; fr certain law enfrcement purpses; t avert a serius threat t health r safety; and t cmply with wrkers' cmpensatin r similar prgrams. Decedents: We may disclse health infrmatin abut a decedent as authrized r required by law. Natinal Security: We may disclse t military authrities the health infrmatin f Armed Frces persnnel under certain circumstances. We may disclse t authrized federal fficials health infrmatin required fr lawful intelligence, cunterintelligence, and ther natinal
security activities. We may disclse t crrectinal institutin r law enfrcement fficial having lawful custdy the prtected health infrmatin f an inmate r patient under certain circumstances. Appintment Reminders: We may use r disclse yur health infrmatin t prvide yu with appintment reminders (such as vicemail messages, pstcards, r letters). Access: Yu have the right t lk at r get cpies f yur health infrmatin, with limited exceptins. Yu may request that we prvide cpies in a frmat ther than phtcpies. We will use the frmat yu request unless we cannt practicably d s. Yu must make a request in writing t btain access t yur health infrmatin. Yu may btain a frm t request access by using the cntact infrmatin listed at the end f this Ntice. Yu may als request access by sending us a letter t the address at the end f this Ntice. We will charge yu a reasnable cst-based fee fr the cst f supplies and labr f cpying. If yu request cpies, we will charge yu $0.10 fr each page, $25.00 per hur fr staff time t cpy yur health infrmatin, and pstage if yu want the cpies mailed t yu. If yu request an alternative frmat, we will charge a cst-based fee fr prviding yur health infrmatin in that frmat. If yu prefer, we will prepare a summary r an explanatin f yur health infrmatin fr a fee. Cntact us using the infrmatin listed at the end f this Ntice fr a full explanatin f ur fee structure. Disclsure Accunting: Yu have the right t receive a list f instances in which we r ur business assciates disclsed yur health infrmatin fr purpses ther than treatment, payment, healthcare peratins, and certain ther activities, fr the last 6 years, but nt befre April 14, 2003. If yu request this accunting mre than nce in a 12-mnth perid, we may charge yu a reasnable, cst-based fee fr respnding t these additinal requests. Restrictin: Yu have the right t request that we place additinal restrictins n ur use r disclsure f yur health infrmatin. In mst cases we are nt required t agree t these additinal restrictins, but if we d, we will abide by ur agreement (except in certain circumstances where disclsure is required r permitted, such as an emergency, fr public health activities, r when disclsure is required by law). We must cmply with a request t restrict the disclsure f prtected health infrmatin t a health plan fr purpses f carrying ut payment r health care peratins (as defined by HIPAA) if the prtected health infrmatin pertains slely t a health care item r service fr which we have been paid ut f pcket in full. Alternative Cmmunicatin: Yu have the right t request that we cmmunicate with yu abut yur health infrmatin byaltemative means r at alternative lcatins. (Yu must make yur request in writing.) Yur request must specify the alternative means r lcatin, and prvide satisfactry explanatin f hw payments will be handled under the alternative means r lcatin yu request. Amendment Yu have the right t request that we amend yur health infrmatin. Yur request must be in writing, and it must explain why the infrmatin shuld be amended. We may deny yur request under certain circumstances. Electrnic Ntice: Yu rnay receive a paper cpy f this ntice upn request, even if yu have agreed t receive this ntice electrnically n ur Web site r by electrnic mail (e-mail). Questins and Cmplaints If yu want mre infrmatin abut ur privacy practices r have questins r cncerns, please cntact us. If yu are cncerned that we may have vilated yur privacy rights, r yu disagree with a decisin we made abut access t yur health infrmatin r in respnse t a request yu made t amend r restrict the use r disclsure f yur health infrmatin r t have us cmmunicate with yu by alternative means r at alternative lcatins, yu may cmplain t us using the cntact infrmatin listed at the end f this Ntice. Yu als may subrnit a written cmplaint t the U.S. Department f Health and Human Services. We will prvide yu with the address t file yur cmplaint with the U.S. Department f Health and Human Services upn request. We supprt yur right t the privacy f yur health infrmatin. with the U.S. Department f Health and Human Services. We will nt retaliate in any way if yu chse t file a cmplaint with us r Cntact Officer: Jhn P. Little. D.M.D.. J.D. Telephne: 732-449-6564 Fax:.!..:73~2::::;;-44=9~-8~6,-,!Ol!.6 ~ E-mail: ilittle555@al.cm Address: 804 Highway 71. Sea Girt. NJ 08750