Notice of Privacy Practices for MEDQUEST ASSOCIATES & SUPPORTED CENTERS

Your Rights

You have the right to:

• Get a copy of your paper or electronic medical record.
• Correct your paper or electronic medical record.
• Request confidential communication.
• Ask us to limit the information we share.
• Get a list of those with whom we’ve shared your information.
• Get a copy of this privacy notice.
• Choose someone to act for you.
• File a complaint if you believe your privacy rights have been violated.

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record.

• You can request to see or obtain an electronic or paper copy of your medical record and other health information. Ask us how to do this.
• We will provide a copy or a summary of your health information, usually within 15 days of your request. We may charge a reasonable, cost-based fee.

Get a list of who we have shared information with

• You can request a list (accounting) of who we shared your health information with during the past six years and why.
• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Correct your medical record.

• You can ask us to correct your health information that is incorrect or incomplete. Ask us how to do this.
• We may need to deny your request, but we’ll tell you why in writing within 60 days.

Request confidential communications.

You can ask us to contact you in a specific way (for example, home or of¬fice phone) or to send mail to a different address. We will say “yes” to all
reasonable requests.

Ask us to limit what we use or share

You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may deny your request if it would adversely affect your care. If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say “yes” unless a law requires us to share that information.

Get a copy of this notice.

You can request a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action.

Your Choices

You have some choices in the way that we use and share information as we:

If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care.
• Share information in a disaster relief situation
• Include your information in a hospital directory.

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases, we never share your information unless you give us written.
permission:

• Marketing purposes
• Sale of your information
• Most sharing of psychotherapy notes

In the case of fundraising:

We may contact you for fundraising efforts, but you can tell us not to contact you again. Your treatment or payment for treatment will not be conditioned on participation of companies fundraising efforts.

Our Uses and Disclosures

We typically use or share your health information in the following ways:

• Treat you.
• Run our organization.
• Bill for your services
• Help with public health and safety issues.
• Do research.
• Comply with the law.
• Work with a medical examiner or funeral director
• Address law enforcement, and other government requests
• Respond to lawsuits and legal actions.
• Business associates to allow them to provide services requested by us to do their job. Example: we may use a company to provide records in a timely manner

Treat you

We can use your health information and share it with other professionals who are treating you.
Example: Our physician sends you to a physical therapist for rehabilitation.

Run our organization.

We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

Bill for your services

We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

Help with public health and safety issues.

We can share health information about you for certain situations such as:

• Preventing disease
• Helping with product recalls
• Reporting adverse reactions to medications
• Reporting suspected abuse, neglect, or domestic violence
• Preventing or reducing a serious threat to anyone’s health or safety

Do research

We can use or share your information for health research.

Comply with the law.

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual has passed.

Legal proceedings, law enforcement, and other government requests

We can use or share health information about you:

• For law enforcement purposes or with a law enforcement official
• With health oversight agencies for activities authorized by law
• For special government functions such as military, national security, and presidential protective services
• Response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.
• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.
• We must follow the duties and privacy practices described in this notice and give you a copy of it.
• In any situation other than those listed above, we may ask for your written authorization before we use or disclose your PHI. If you sign a written authorization allowing us to disclose PHI, you can cancel it later. Your cancellation must be in writing and delivered to the Privacy Official at the address provided below. We will not disclose PHI about you previously authorized after we receive your cancellation and had a reasonable time to implement the cancellation.

Appointment Reminders & Patient Communications:

We will communicate reminders, confirmations and information of interest
designed to improve your customer experience and oral health if you provide your contact information including, mailing address, phone number, email address and/or you opt in to text messages. We may use automated dialing technology and pre-recorded messages to confirm your appointment information, using any phone number you provide to us. Our communications to you will only disclose PHI to confirm your contact and insurance information, remind you and/or your child of an appointment, or to inform you and/or your child of treatment alternatives or other health-related benefits and services that may be of interest to you. Please inform us immediately if any of your contact information changes.

We may also email you or send mail to you that has information about services we offer at the office where you or other members of your family receive care.

Changes to the Terms of this Notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our web site.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us using the information here.
• We will not retaliate against you for filing a complaint

You can file a complaint with our Privacy Officer through our HOTLINE services.

Website: https://report.syntrio.com/mqimaging

Toll-Free Telephone:

English-speaking USA and Canada: 833-561-2998
Spanish-speaking USA and Canada: 800-216-1288
Spanish-speaking Mexico: 800-681-5340
French-speaking Canada: 855-725-0002

E-mail: [email protected] must include name of center in the report email description

Fax: 215-689-3885 must include company name with report

We also welcome suggestions through our suggestion box https://report.syntrio.com/mqimaging/sb.asp

Additionally, for more information or to file a complaint you can contact the US Department of Health and Human Services Office for Civil Rights you can send a letter to:

200 Independence Avenue, S.W., Washington, D.C. 20201, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

*The HIPAA privacy rule establishes a national minimum standard. If a state law provides greater privacy protections, the state law must be observed.

This Notice of Privacy Practices applies only to care and treatment you receive at this facility or other MedQuest facilities that are treated as an “affiliated covered entity” under the federal law known as the Health Insurance Portability and Accountability Act (HIPAA) that protects the privacy of your health information. Terms defined in the HIPAA Rules will have the same meaning in this Notice.