Our office is located at:
183 S. Bloomingdale Rd
The Lastest technology is essential in providing you the best quality care possible. Associated Dental Care utilizes the most recent technology available.
Even the most subtle change in your smile can make a dramatic difference in the way you look and feel about yourself.
Everybody loves a bright white smile, and there are a variety of products and procedures available to help you improve the look of yours.
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.
Under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), all medical records and other individually identifiable health information of which we have knowledge must be kept confidential. All personal health information used by us or disclosed by us is covered by this Act regardless of whether this personal health information is electronic, oral or paper form. Several new rights are granted to patients under this Act, allowing control over how your personal health information is used, how you can access it, and in some cases amend it.
We are required by law to maintain the privacy of your personal health information and to provide you with notice of our legal duties and privacy practices with respect to your personal health information.
We may be assessed a penalty for any misuse or unauthorized disclosure of your personal health information as regulated by HIPAA.
This Notice of Privacy Practices is effective on April 14, 2003.
We are bound to abide by the terms of this notice and reserve the right to make revisions to this policy. Should revisions be made, you will be notified in writing, and a copy of the revised policy will be made available at your request.
You will be asked to sign a form authorizing us to use and disclose your personal health information only for the following purposes, as defined under the Act:
Treatment means the provision, coordination, or management of health care and related services by one or more healthcare providers, including the coordination or management of health care by a healthcare provider with a third party; consultation between healthcare providers relating to a patient; or the referral of a patient for health care from one healthcare provider to another. An example of this would be a dentist referral to an orthodontist.
Payment means obtaining reimbursement for the provision of health care; determinations of eligibility or coverage; billing; claims management; collection activities; justification of charges; and disclosure to consumer reporting agencies; protected health information relating to the collection of reimbursements (only certain information may be disclosed). An example of this would be submitting your bill for health care services to your insurance company.
Health care operations are any activity related to covered function in which we participate in the function of our offices, such as conducting quality assessment activities; protocol development; case management and care coordination; auditing function; business management and general administrative activities, including implementation of this regulation; customer service evaluations; resolution grievances; fundraising; and marketing for which an authorization is not required. An example of this would be evaluation customer service given to patients.
We may, without prior consent use or disclose your personal health information to carry out treatment, payment or health care operations:
Directly to you at your request;
In an emergency treatment situation. If we attempt to obtain such consent as soon as reasonably practicable after the delivery of such treatment, if we are required by law to treat you and attempts to obtain consent are unsuccessful, or if we attempt to obtain consent but are unable, due to barriers of communication, but we determine in our professional opinion that treatment is clearly inferred from the circumstances;
Pursuant to and in compliance with an authorization signed by you;
To a family member, friend, personal representative, or other individual to the extent necessary to coordinate health care or payment for health care; and
Provided that you are informed of the use and disclosure and have the opportunity to prohibit or restrict the use or disclosure. This may be an oral agreement between us and may include a directory maintained at our facility containing specific information allowed by this Act.
We may de-identify your personal health information by using codes or removing all individually identifiable health information
All other uses and disclosure will be made only upon securing a written authorization form signed by you. You have the right to revoke this authorization, at any time, upon written notice and we will abide by that request. However, exception would be any actions already taken, relying on your authorization, prior to revocation notice.
We may contact you to provide appointment reminders or to inform you about treatment alternatives or other health related benefits or services that may be of interest to you. We may also contact you for fundraising purposes.
Under HIPAA, you have the following rights with respect to your protected health information:
You have the right to request restrictions on certain uses and disclosures of protected health information, including restrictions place upon disclosure to family members, close personal friends, or any other person you may identify. We are, however, not required to agree with a requested restriction;
You have the right to receive confidential communication of your protected health information, either directly from us or by alternative means or from alternative locations;
You have the right to inspect and copy your protected health information;
You have the right to amend protected health information, however, this request may be denied under certain circumstances;
You have the right to receive an accounting of disclosures of your protected health information made by us in the six years prior to the date of the accounting request; and
You have the right to obtain a paper coy of this notice from us, even if you have already agreed to receive the notice electronically
If you feel your privacy right or the provision if this notice of privacy policies has been violated, you have the right to file a formal written complaint. This complaint should be addressed either to the Privacy Officer at our office, or directly to the Department of Health & Human Services, Office of Civil Rights. Both addresses appear below. You will not be retaliated against, in any way, for filing a complaint.
For more information about HIPPA
Or to file a complaint, contact:
The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, DC 20201
Toll free: (877) 696-6775
183 S. Bloomingdale Rd. STE 202
Bloomingdale, IL 60108
(630) 894-1148 – Fax