notice of privacy practices (npp) · 2020. 5. 20. · notice of privac y prac tices (npp) 3 we may...

Notice of Privacy Practices (NPP)Instructions for Use!e following are the REQUIRED changes to the NPP. Please review and ensure the current NPP in use is revised to include these items:

• Statement which outlines the types of uses and disclosures which will require authorization.• Release of psychotherapy notes – Do not have to include if do no record or maintain this information.• Disclosures for marketing purposes.• Disclosures for any purposes which require the sale of PHI.

• Statement that other uses and disclosures will not be made without written authorization.• Notice of updated rights:

• Right to restrict certain disclosures of protected health information to a health plan where the individual pays out of pocketin full for the health care item or service.

• Will receive notification in the event of a breach scenario.• Notice of fundraising communications and the opportunity to opt out.

• Not required to include the opt-out processTMC is pleased to provide an example of an updated NPP, which includes verbiage required by the recently published OmnibusHIPAA Rules. Please review the NPP carefully to ensure it reflects the current process of your facility. !is NPP can be located inelectronic format on our website in the Client Portal under HIPAA Forms.

Page 1

• Be sure to insert the name of your practice or facility.• Contact information of the Privacy Officer should be included. !e actual name of the person can be included, but PRIVACY

OFFICER and contact information is sufficient. !e rationale behind not including the actual name of the person is that if theyshould leave your organization, the NPP would need to be updated to include the current person holding the title.

• !e effective date is the original date your facility adopted a NPP, which for many will be the April 2003 date. !e revision date isthe date you adopt the updated Notice.

Pages 2 – 4

• Review these pages carefully deleting any activities in which your facility does not participate, for instance fundraising activities,or providing appointment reminders.

• On page 4 in the section which outlines disclosures requiring a signed authorization, carefully review the definition ofpsychotherapy notes. If your facility does not create or receive this type of protected health information you may delete thisstatement from your Notice. !e statement about marketing and disclosures for sale of PHI must remain.

Providing the updated Notice of Privacy Practices• Direct care providers are not required to print and hand out a revised NPP to all individuals seeking treatment. Providers are only

required to give a copy of the NPP to, and obtain a good faith acknowledgment of receipt from, NEW patients.

Posting of the updated Notice of Privacy Practices• Providers must post the revised NPP in a clear and prominent location and have copies of the NPP at the delivery site for

individuals to request to take with them.• Health care providers are required to post the NPP in a clear and prominent location at the delivery site, however providers may

post a summary of the Notice in such a location as long as the full notice is immediately available (such as on a table directlyunder the posted summary) for individuals to pick up without any additional burden on their part. It would not be appropriate,however, to require the individual to have to ask the receptionist for a copy of the full NPP.

• If the facility has a website, the updated NPP must be posted on the website.

www.wakeorthopedo.com • (919) 719-1780

Notice of Privacy Practices (NPP) 2

Wake Orthodontics and Pediatric DentistryNotice of Privacy Practices

!is 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.

If you have any questions about this Notice please contact the Privacy Officer at919-848-1882

Revised: August 27, 2015

We are committed to protect the privacy of your personal health information (PHI).

!is Notice of Privacy Practices (Notice) describes how we may use within our practice or network and disclose (share outside of ourpractice or network) your PHI to carry out treatment, payment or health care operations. We may also share your information forother purposes that are permitted or required by law. !is Notice also describes your rights to access and control your PHI.

We are required by law to maintain the privacy of your PHI. We will follow the terms outlined in this Notice.

We may change our Notice, at any time. Any changes will apply to all PHI. Upon your request, we will provide you with any revisedNotice by:

• Posting the new Notice in our office.• If requested, making copies of the new Notice available in our office or by mail.• Posting the revised Notice on our website: www.wakeorthopedo.com

Uses and Disclosures of Protected Health Information

We may use or disclose (share) your PHI to provide health care treatment for you.Your PHI may be used and disclosed by your physician, our office staff and others outside of our office that are involved in yourcare and treatment for the purpose of providing health care services to you.

EXAMPLE: Your PHI may be provided to a physician to whom you have been referred for evaluation to ensure that the physicianhas the necessary information to diagnose or treat you. We may also share your PHI from time-to-time to another physician orhealth care provider (e.g., a specialist or laboratory) who, at the request of your physician, becomes involved in your care byproviding assistance with your health care diagnosis or treatment to your physician.

We may also share your PHI with people outside of our practice that may provide medical care for you such as home healthagencies.

We may use and disclose your PHI to obtain payment for services. We may provide your PHI to others in order to bill or collectpayment for services. !ere may be services for which we share information with your health plan to determine if the service will bepaid for.

PHI may be shared with the following:

• Billing companies• Insurance companies, health plans• Government agencies in order to assist with qualification of benefits• Collection agencies

EXAMPLE: You are seen at our practice for a procedure. We will need to provide a listing of services such as x-rays to your insurancecompany so that we can get paid for the procedure. We may at times contact your health care plan to receive approval PRIOR toperforming certain procedures to ensure the services will be paid for. !is will require sharing of your PHI.



We may use or disclose, as-needed, your PHI in order to support the business activities of this practicewhich are called health care operations.

EXAMPLES:

• Training students, other health care providers, or ancillary staff such as billing personnel to help them learn or improve theirskills.

• Quality improvement processes which look at delivery of health care and for improvement in processes which will provide safer,more effective care for you.

• Use of information to assist in resolving problems or complaints within the practice.

We may use and disclosure your PHI in other situations without your permission:• If required by law: !e use or disclosure will be made in compliance with the law and will be limited to the relevant requirements

of the law. For example, we may be required to report gunshot wounds or suspected abuse or neglect.• Public health activities: !e disclosure will be made for the purpose of controlling disease, injury or disability and only to public

health authorities permitted by law to collect or receive information. We may also notify individuals who may have beenexposed to a disease or may be at risk of contracting or spreading a disease or condition.

• Health oversight agencies: We may disclose protected health information to a health oversight agency for activities authorized bylaw, such as audits, investigations, and inspections. Oversight agencies seeking this information include government agenciesthat oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.

• Legal proceedings: To assist in any legal proceeding or in response to a court order, in certain conditions in response to asubpoena, or other lawful process.

• Police or other law enforcement purposes: !e release of PHI will meet all applicable legal requirements for release.• Coroners, funeral directors: We may disclose protected health information to a coroner or medical examiner for identification

purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law• Medical research: We may disclose your protected health information to researchers when their research has been approved by

an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of yourprotected health information.

• Special government purposes: Information may be shared for national security purposes, or if you are a member of the military,to the military under limited circumstances.

• Correctional institutions: Information may be shared if you are an inmate or under custody of law which is necessary for yourhealth or the health and safety of other individuals.

• Workers’ Compensation: Your protected health information may be disclosed by us as authorized to comply with workers’compensation laws and other similar legally-established programs.

Other uses and disclosures of your health information.Business Associates: Some services are provided through the use of contracted entities called “business associates”. We willalways release only the minimum amount of PHI necessary so that the business associate can perform the identified services. Werequire the business associate(s) to appropriately safeguard your information. Examples of business associates include billingcompanies or transcription services.

Health Information Exchange: We may make your health information available electronically to other healthcare providersoutside of our facility who are involved in your care.

Fundraising activities: We may contact you in an effort to raise money. You may opt out of receiving such communications.

Treatment alternatives: We may provide you notice of treatment options or other health related services that may improve youroverall health.

Appointment reminders: We may contact you as a reminder about upcoming appointments or treatment.



We may use or disclose your PHI in the following situations UNLESS you object.• We may share your information with friends or family members, or other persons directly identified by you at the level they are

involved in your care or payment of services. If you are not present or able to agree/object, the healthcare provider usingprofessional judgment will determine if it is in your best interest to share the information. For example, we may discuss postprocedure instructions with the person who drove you to the facility unless you tell us specifically not to share the information.

• We may use or disclose protected health information to notify or assist in notifying a family member, personal representative orany other person that is responsible for your care of your location, general condition or death.

• We may use or disclose your protected health information to an authorized public or private entity to assist in disaster reliefefforts.

!e following uses and disclosures of PHI require your written authorization:• Marketing• Disclosures of for any purposes which require the sale of your information

All other uses and disclosures not recorded in this Notice will require a written authorization from you or your personalrepresentative.

Written authorization simply explains how you want your information used and disclosed. Your written authorization may berevoked at any time, in writing. Except to the extent that your doctor or this practice has used or released information based on thedirection provided in the authorization, no further use or disclosure will occur.

Your Privacy RightsYou have certain rights related to your protected health information. All requests to exercise your rights must be made in writing.[Describe how the patient may obtain the written request document and to whom the request should be directed, i.e. practicemanager, privacy officer.]

You have the right to see and obtain a copy of your protected health information.!is means you may inspect and obtain a copy of protected health information about you that is contained in a designatedrecord set for as long as we maintain the protected health information. If requested we will provide you a copy of your records inan electronic format. !ere are some exceptions to records which may be copied and the request may be denied. We may chargeyou a reasonable cost based fee for a copy of the records.

You have the right to request a restriction of your protected health information.You may request for this practice not to use or disclose any part of your protected health information for the purposes oftreatment, payment or healthcare operations. We are not required to agree with these requests. If we agree to a restrictionrequest we will honor the restriction request unless the information is needed to provide emergency treatment.

!ere is one exception: we must accept a restriction request to restrict disclosure of information to a health plan if you pay outof pocket in full for a service or product unless it is otherwise required by law.

You have the right to request for us to communicate in different ways or in different locations.We will agree to reasonable requests. We may also request alternative address or other method of contact such as mailinginformation to a post office box. We will not ask for an explanation from you about the request.



You may have the right to request an amendment of your health information.You may request an amendment of your health information if you feel that the information is not correct along with anexplanation of the reason for the request. In certain cases, we may deny your request for an amendment at which time you willhave an opportunity to disagree.

You have the right to a list of people or organizations who have received your health information from us.!is right applies to disclosures for purposes other than treatment, payment or healthcare operations. You have the right toobtain a listing of these disclosures that occurred after April 14, 2003. You may request them for the previous six years or ashorter timeframe. If you request more than one list within a 12 month period you may be charged a reasonable fee.

Additional Privacy Rights• You have the right to obtain a paper copy of this notice from us, upon request. We will provide you a copy of this Notice the first

day we treat you at our facility. In an emergency situation we will give you this Notice as soon as possible.• You have a right to receive notification of any breach of your protected health information.

ComplaintsIf you think we have violated your rights or you have a complaint about our privacy practices you can contact:

[THE PRIVACY OFFICER at 919-848-1882 or [email protected]]

You may also complain to the United States Secretary of Health and Human Services if you believe your privacy rights have beenviolated by us.

If you file a complaint we will not retaliate against you for filing a complaint.

!is notice was published and becomes effective on February 10, 2003.


Acknowledgement of Receipt of Notice of Privacy Practices

Wake Orthodontics and Pediatric Dentistry

Name of Patient ____________________________________________________________________________

Our office is happy to provide a copy of the Notice of Privacy Practices upon request.

____________________________________________________________ ____________________

For Office Use Only

We were unable to obtain a written acknowledgement of receipt of the Notice of Privacy Practices because:

! An emergency existed & a signature was not possible at the time.

! "e individual refused to sign.

! A copy was mailed with a request for a signature by return mail.

! Unable to communicate with the patient for the following reason:

________________________________________________________________________________________

! Other:

________________________________________________________________________________________

Prepared By: ______________________________________________________________________________

Signature__________________________________________________________________________________

Date ____________________________________________________________________________________


Signature Date of Birth

Authorization for Release of InformationWake Orthodontics and Pediatric Dentistry

Name of Patient ____________________________________________________________________________

Date of Birth ______________________________________________________________________________

Wake Orthodontics & Pediatric Dentistry is authorized to release protected health information about the abovenamed patient to the entities named below. !e purpose is to inform the patient or others in keeping with thepatient's instructions.

Entity to Receive Information. Description of information to be released.Check each person/entity that you approve to Check each that can be given to person/entity onreceive information. the left in the same section.

! Voice Mail. Email or Text ! Appointment remindersOther

! Spouse (provide name & phone number) ! Financial ! Treatment notes:

! Parent (provide name & phone number) ! Financial ! Treatment notes:

! Other (provide name & phone number ! Financial ! Treatment notes:

Patient InformationI understand that I have the right to revoke this authorization at any time and that I have the right to inspect or copythe protected health information to be disclosed as described in this document. I understand that a revocation isnot effective in cases where the information has already been disclosed but will be effective going forward.

I understand that information used or disclosed as a result of this authorization may be subject to redisclosure bythe recipient and may no longer be protected by federal or state law.

I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned onsigning. !is authorization shall be in effect until revoked by the patient.

____________________________________________________________ Date_______________________

Signature of Patient or Personal Representative


Authorization for Release of PhotographsWake Orthodontics and Pediatric Dentistry

Name of Patient ____________________________________________________________________________

Date of Birth ______________________________________________________________________________

Wake Orthodontics and Pediatric Dentistry is authorized to release photographs of the above named patient to theentities below. !e purpose is to inform the patient or others in keeping with the patient’s instructions.

Entity to Receive Photographs:

! Our Website ! Facebook ! Instagram ! Twitter ! Pinterest

Check each entity that you approve.

I understand that I have to the right to refuse to sign this authorization. !is authorization shall be in effect untilrevoked by patient.

____________________________________________________________ Date_______________________

Signature of Patient or Personal Representative


Success.ADA.org | © 2016 American Dental Association. All rights reserved. 1

North Carolina We will take reasonable steps to provide free-of-charge language assistance services to people who speak languages we are likely to hear in our practice and who don’t speak English well enough to talk to us about the dental care we are providing. Spanish: Tomaremos acciones razonables para proporcionar servicios de asistencia lingüística gratuitos a aquellas personas cuyo lenguaje escuchemos frecuentemente en nuestro consultorio y que no hablen un inglés lo suficientemente bueno como para hablar con nosotros sobre el servicio odontológico que suministramos.

Chinese: 我们将有序地做到提供免费语务使我们听懂语不好人向我们咨询有关齿护

Vietnamese: Chúng tôi s th c hi n các b c c n thi t đ cung c p d ch v h tr ngôn ng mi n phí cho nh ng ng i giao ti p b ng nh ng ngôn ng mà chúng tôi có th nghe th y t i phòng khám c a mình và cho nh ng ng i không có đ trình đ ti ng Anh đ th o lu n v d ch v chăm sóc nha khoa mà chúng tôi đang cung c p.

Korean: 저희는 적절한 조치를 통하여 언어 지원 서비스를 무료로 제공할 것입니다. 다만, 실제로 저희에게 관심이 있는

언어를 쓰지만 저희 치아 관리 서비스에 대해 의견을 줄 수 있을 만큼 영어로 의사소통이 원활하지 않는 경우로

한정합니다

French: Nous prendrons les mesures raisonnables pour fournir des services d'assistance linguistique gratuits pour les individus qui parlent des langues que nous sommes susceptibles d'entendre durant nos séances et qui ne parlent pas suffisamment bien l'anglais pour discuter avec nous concernant les soins dentaires que nous fournissons.

Arabic:

اذ ات ر ف ات أ دث ت ذ اص ا فة د ت ة دة ا ا ات ا د ر ف ة أ ت ات طا ة ا ا ر ت ا ا ف دث إ ت د ا ة ز دث ا ت ت ذ ا ا ت ار ا ت إ ر أ ا

ا. د ت ا

Hmong: Peb yuav tsum nrhiav kev pab-dawb los ntawm kev pab cuam txhais lus rau cov neeg uas hais lus peb yeej tau hnov hauv peb txoj kev kawm thiab tus uas tsis paub hais lus Askiv txaus los tham rau peb txog cov kev pab kho hniav peb muaj.

Russian: Мы принимаем необходимые меры, чтобы предоставить бесплатные услуги переводчика дл общени на зыках, с которыми мы сталкиваемс в нашей практике с клиентами, которые не владе т английским зыком достаточно, чтобы обсудить с нами стоматологическое обслуживание, которое мы предоставл ем.

Tagalog: Gagawin namin ang mga makatwirang hakbang para maibigay namin ng walang bayad ang mga tulong na serbisyo sa wika para sa mga taong nagsasalita ng mga wikang karaniwan naming naririnig sa aming pagsasagawa at sa mga hindi bihasa sa pagsasalita ng Ingles na sasangguni sa amin tungkol sa pangangalaga ng ngipin na ibinibigay namin.

Success.ADA.org | © 2016 American Dental Association. All rights reserved. 2

Gujarati: અમ એવા લ ક ન વવના ય ભાષા સહાય સવા ર પાડવા ઉિત પગલાાં લઇ ાં ઓ એ ભાષાઓ બ લ છ અમન (તબીબી ) કટ સમાાં સાાંભળવા મળ શક અન ઓ અમ દાંત ર ા દાન કર એ છ એ તના વવષ વાત કરવા ર ાં ય ય લીશ બ લી શકતા નથી.

Mon-Khmer, Cambodian: ងខនង ត ន ម តផ ដមបផដ ជនន ជន តគត លដ នកន ដ ង

ខចង ដ ប កន ង ន តត ប ងខ នង នក ដ ន ង គ មន ន កន ង ន មក ន ងខ ព ល ត មេញ ដ ងខកពងផដ

German: Wir werden angemessene Schritte unternehmen, um denen eine gebührenfreie Sprachunterstützung zu bieten, die Sprachen sprechen, die wir möglicherweise in unserer Praxis hören, die aber kein Englisch sprechen, das gut genug ist, um mit uns über die Zahnpflege zu sprechen, die wir anbieten.

Hindi: हम उन य तिय क , ज क ऐस भ ष ए ब लि ह ज हम अपन अ य स म सभ िि प म सनन च हि ह और ज हम र ि र द न क ज न ि ल डटल दखभ ल क ब र म हम र स थ उ चि ढग स अ ज नह ब लि, म ि सि ए द न करन क लय उ चि

कदम उठ यग।

Laotian: ພວກເຮາຈະໃຊຂນຕອນທເໝາະສມ ເພອໃຫບລິ ການຊວຍເຫອດານພາສາບເສຍຄາແກຄນຜທເວາພາສາທພວກເຮາອາດຈະໄດຍິ ນຢໃນການຝກຊອມຂອງພວກເຮາ ແລະ ຜທບເວາພາສາອງກິດໄດດພ ເພອລມກບພວກເຮາກ ວກບການເບິ ງແຍງດແລແຂວທພວກເຮາກາລງຈດໃຫ.

Japanese: 実中く可性があ人々、弊が提供しいい、が

上手い人々、償支援ー提供合措。

Reproduction of this material by member dentists and their staff is permitted for non-commercial use in their dental offices, on their websites, and on publications and communications for purposes of compliance with the Section 1557 final rule. Any other use, duplication or distribution by members or any other party requires the prior written approval of the American Dental Association. This material is for general reference purposes only and does not constitute legal advice. It covers only the Section 1557 final rule tagline requirement, not other federal or state law. Changes in applicable laws or regulations may require revision. Dentists should contact qualified legal counsel for legal advice, including advice pertaining to compliance with Section 1557 of the Affordable Care Act, and the U.S. Department of Health and Human Services rules and regulations. © 2016 American Dental Association. All rights reserved.

NOTICE OF NONDISCRIMINATIONSource: HHS Office for Civil Rights

Wake Orthodontic & Pediatric Dentistry complies with applicable Federal civil rights laws and does notdiscriminate on the basis of race, color, national origin, age, disability, or sex.

Wake Orthodontic & Pediatric Dentistry does not exclude people or treat them differently because of race, color,national origin, age, disability, or sex.

Wake Orthodontic & Pediatric Dentistry:• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

o Qualified sign language interpreterso Written information in other formats (large print, audio, accessible electronic formats)

• Provides free language services to people whose primary language is not English, such as:o Qualified interpreterso Information written in other languages

If you need these services, contact Laura Brown, Clinical Practice Manager.

If you believe that Wake Orthodontic & Pediatric Dentistry has failed to provide these services or discriminated inanother way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Laura Brown, Clinical Practice Manager7401 Creedmoor RdRaleigh, NC 27613(919) 866-4550FAX: (919) [email protected]

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Laura Brown, ClinicalPractice Manager is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for CivilRights electronically through the Office for Civil Rights Complaint Portal, available athttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services200 Independence Avenue SW.Room 509F, HHH BuildingWashington, DC 20201Toll Free: 1-800-868-1019, 800-537-7697 (TDD).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.


notice of privacy practices (npp) · 2020. 5. 20. · notice of privac y prac tices (npp) 3 we may...

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