Notice of Privacy Practices


This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your dentist, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the dentist’s practice, and any other use required by law.

Treatment: We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your PHI, as necessary, to a home health agency that provides care to you. For example, your PHI may be provided to a Dental Specialist to whom you have been referred to ensure that the Specialist has the necessary information to diagnose or treat you.

Payment: Your PHI will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for dental procedure may require that your relevant PHI be disclosed to the health plan to obtain approval for the dental procedure.

Health Care Operations: We may use or disclose, as needed, your PHI in order to support the business activities of your dentist’s practice. These activities include, but are not limited to quality assessment activities, employee review activities, training of dental students, licensing, and conducting or arranging for other business activities. For example, we may disclose your PHI to dental school students that see patients at our office. We may also call you by name in the waiting room when your dentist is ready to see you. We may use or disclose your PHI, as necessary, to contact you to remind you of your appointment.

We may use or disclose your PHI in the following situations without your authorization. These situations include: as Required By Law – Public Health Agencies: Victims of Abuse, Neglect or Domestic Violence: – Communicable Disease:- Health Oversight:- Abuse or Neglect:- Serious Threats to Health or Safety: Food and Drug Administration requirements:- Judicial and Administrative Proceedings:- Law Enforcement-: Coroners, Funeral Directors, and Organ Donation:- Research:- Criminal Activity: – Military Activity and National Security: – Workers’ Compensation: – Inmates:- Incidental Uses and Disclosures: Friends and Family Involved In Your Case: – Required Uses and Disclosures: – under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

We are required to obtain your written authorization in the following circumstances; (a) to use your PHI for marketing purposes: (b) to sell your PHI; and (c) to use or disclose your PHI for any purpose not previously described in this Notice.

We also will obtain your authorization before using or disclosing your PHI when required to do so by (a) state law, such as laws restricting the use or disclosure of genetic information or information concerning HIV status; or (b) other federal law, such as federal law protecting the confidentiality of substance abuse records. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization.

Your Rights: Following is a statement of your rights with respect to your PHI. You have the right to inspect and copy your PHI. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and PHI that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your PHI. This means you may ask us not to use or disclose any part of your PHI for the purposes of treatment, payment or health care operations. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in the Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your dentist is not required to agree to a restriction that you may request unless (a) you request that we not disclose your PHI to a health insurance company, Medicare or Medicaid for payment or health care operations purposes: (b) you, or someone on your behalf, has paid us in full for the health care item or service to which the PHI pertains; and (c) we are not required by law to disclose to the insurer, Medicare, or Medicaid the PHI that is the subject of your request. If the dentist believes it is in your best interest to permit use and disclosure of your PHI, your protected health information will not be restricted. You then have the right to use another Health Care Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, i.e. electronically.

You may have the right to request that your dentist amend your PHI if you believe it is incorrect or incomplete. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You must provide us with a reason that supports your request for amendment. We will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate and complete; (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by us, unless the individual or entity that created the information is not available to amend the information.

You have the right to receive an accounting of certain disclosures we have made, if any, of your PHI. The accounting will exclude the following disclosures: (a) disclosures for “treatment,” “payment,” or “healthcare operations”; (b) disclosures to you or pursuant to your authorization; (c) disclosures to family members or close friends involved in your care or in payment for your care; (d) disclosures as part of a data use agreement; and (e) incidental disclosures. We will provide the first accounting during and 12-month period without charge. We may charge a reasonable, cost-based fee for each additional accounting during the same 12-month period. If there will be a charge, our Privacy Official will first contact you to determine whether you wish to modify or withdraw your request.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You have the right to object or withdraw as provided in this notice.

Right To Receive Notice Of A Breach Of Your Unsecured PHI: If we discover a breach of your unsecured PHI, we will notify you of the breach and provide the information required by law.

Complaints: You may complain to us or to the Secretary of Health and Human Services. Hubert H Humphrey Building, 200 Independence Ave., S.W. Washington, DC 20201, if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

This notice was published and becomes effective on/or before September 23, 2013.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to PHI. If you have any questions about this form, or wish to file a complaint, please ask to speak with our HIPAA Compliance Officer, Dr. Fantasia, 372 Washington Street, Wellesley, MA 02481, Matthew R. Fantasia, DMD, PC Phone Number (781) 235-1146.

We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this Notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.