Effective date of Notice: May 1, 2019
NOTICE OF PRIVACY PRACTICES FOR ALL DENTAL PRACTICES AFFILIATED WITH OR CONTRACTING WITH CLEARFY IN REGARD TO THE PROVISION OF CLEAR ALIGNER THERAPY
c/o Clearfy, 1930 S Dixie Hwy STE C6, West Palm Beach, FL 33401
THIS NOTICE COMMUNICATES HOW YOUR PERSONAL AND HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. This Notice describes how we protect your health information and what rights you have regarding your health information. If you have any questions about this Notice, please contact the contact person shown above.
USES AND DISCLOSURES WITHOUT YOUR CONSENT
For certain purposes we may disclose your health information without your authorization, including the following:
Treatment, Payment and Health Care Operations:
The most common reason why we use or disclose your health information is for treatment, payment or health care operations.
Treatment: In order to treat you, we may use or disclose your information. Treatment may include, but is not limited to, the development of a draft treatment plan or to communicate with a dental laboratory regarding dental appliances being developed or modified for you, setting an appointment for you, performing a dental or physical examination, performing diagnostic tests, prescribing medications and faxing or sending them electronically to be filled, referring you to another health care provider for additional or specialist services, or getting copies of your health information from another health care provider that you may have seen before.
Payment: In order to obtain payment for the services we provide to you, we may use or disclose your information. Such instances include, but are not limited to, using your information to inquire you or your insurance company about your dental insurance coverage or other sources of payment, to prepare and send bills or claims, or to collect unpaid amounts (either ourselves or through a contracted third-party).
Health Care Operations: For certain administrative and managerial activities that are necessary for us to run our business, we may use or disclose your information. Such instances include, but are not limited to, disclosing your information to train or evaluate our staff, conducting financial or billing audits to conduct internal quality assurance, participating in managed care plans, defending legal matters, conducting business planning, or contracting for storage of our records.
You May Object to Disclosures: We may release health information about you to a friend, family member or other person who is involved in your medical and dental care, except with your explicit instruction not to.
OTHER USES AND DISCLOSURES
In order to remind you of scheduled appointments or the need to make a routine appointment, including for dental monitoring, we may need to call, write, e-mail or message you, i.e. “communicate”. We may also communicate to notify you of other treatments or services available that might help you.
Further, we may communicate to follow up, conduct quality assessment, ask for reviews, feedback, assessment of satisfaction, complaints or similar activities.
We will not use your information for marketing purposes without your authorization. You understand that if we contact you to seek authorization for marketing, and if you decline to provide such consent this will not affect your treatment and we will not repeatedly bother you for such authorization.
We may also use or disclose your information without your permission, in some limited situations and if certain conditions are satisfied. These are some of the disclosures that may occur, but are not guaranteed to occur, and some disclosures will not be by us, but at the jurisdiction of state or federal laws:
USES AND DISCLOSURES PER YOUR CONSENT
Unless you sign a written “authorization form”, we will not make any other uses or disclosures of your information. Federal law determines the content of said “authorization form”. We may initiate the authorization process if the use or disclosure is our idea, but you may initiate the process if it is your idea for us to send your information to someone else.
In situations such as the prior, you will give us a properly completed authorization form or you can use one of ours.
You do not have to sign the authorization form if we initiate the process and ask you to sign it. If you choose not to sign the authorization, we cannot make the use or disclosure.
You may revoke the authorization form at any time unless we have already acted in reliance upon it. Your withdrawal of authorization must be in writing and sent to the contact address named at the beginning of this Notice.
Before disclosing any information relating to treatment for mental health, substance abuse, HIV or AIDS, we will request your authorization. We will also request your written authorization for most uses and disclosures of any psychotherapy notes, your health information for marketing purposes, and for the sale if your health information.
YOUR RIGHTS CONCERNING YOUR HEALTH INFORMATION
You many rights regarding your health information as governed by the law. To request any of the following, send a written request to the contact address named at the beginning of this Notice:
We must abide by the terms of this Notice of Privacy Practices and we reserve the right to change this Notice at any time, as dictated by law. If we change this Notice, the new privacy practices will apply to all health information that we maintain and all information that we may generate in the future. If we change our Notice of Privacy Practice, it will be readily available and posted in our office and on our website.
COMPLAINTS OR FOR MORE INFORMATION
You are welcome to complain to us or to the U.S. Department of Health and Human Services, Office for Civil Rights, should you think that we have not properly respected the privacy of your health information and we will not retaliate against you if you make a complaint. Should you want to complain to us, send a written complaint to the contact address or e-mail shown at the beginning of this Notice. Or at your preference, you can discuss your complaint in-person in store, or by phone.
If you want more information about our privacy practices, call us, visit the contact address or e-mail us at the respective contact information shown at the beginning of this Notice.
This Notice is effective May 1, 2019.