Jacquelyn Grillo DDS
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.
What is this notice and why is it important?
By law Jacquelyn Grillo DDS, Inc, which includes employed doctors, assistants, hygienists, and front office staff, are requires to protect the privacy of your identifiable medical and other health information.
The office is also required by law to give you this notice to tell you how we may use and give out (“disclose”) your protected health information held by our office and its health care practitioners. The office must follow the terms of this notice when using or disclosing your protected health information. The office is required to obtain your permission before using or disclosing your protected health information, except as described as below. This notice is effective as of April 14, 2003.
How may the office use your protected health information?
The office generally is required to obtain your written authorization (“permission”) before using your protected health information. This section explains those situations where, under federal law, the office may use or disclose your protested health information without your permission.
The office does not need to obtain your written permission to use your protected health information for the following purposes:
Treatment: We use and disclose your protected health information to provide health care services to you. This includes uses and disclosures to:
Treat your illness or injury.
Contact you to provide appointment reminders.
Give you information about alternative or other health related benefits and services that may interest you.
Payment: We may use and disclose your protected health information to obtain payment for health care services that we or others provide to you. This includes uses and disclosures to:
Submit and obtain payment from your health insurer, PPO, or other company that pays the cost of some or all of your health care.
Verify that your payer will pay for your health care.
Health Care Operations: We may use and disclose your protected health information for our health care operations, such as internal administration and planning that improve the quality and cost effectiveness of the care that we provide to you. This also includes uses and disclosures to:
Evaluate the quality and competence of our health care providers, staff, and other health care workers.
Train students, residents, and fellows.
We may disclose your protected health care information to third parties to assist in these activities, but only if they agree in writing to maintain the confidentiality of your health information. We may disclose your protected health care information to your health care providers, to enable them to conduct their own quality review, compliance activities, and other health care operations. Our office works together with other health care providers sharing information to insure quality care, compliance, and patient education.
In addition, our office may use and disclose your protected health information under the following circumstances:
Relatives, Caregivers, and Personal Representatives: Under appropriate circumstances, including emergencies, We may disclose protected health care information to relatives, caregivers, or personal representatives who are with you or appear on your behalf (for example, to pick up a prescription). We may also need to notify such a person of your location in our facility and general condition. If you object to such disclosures, please notify us.
Public Health Activities: We may disclose your protected health care information for the following public health activities:
To report to public health authorities for the purpose of preventing or controlling disease, injury, or disability.
To report information to the US Food and Drug Administration (FDA) and products and services under its jurisdiction.
To alert a person who may have been exposed to communicable disease or may otherwise be at risk of contracting or spreading a disease.
Victims of Abuse, Neglect, or Domestic Violence: If we reasonably believe that you are a victim of abuse, neglect, or domestic violence, we may disclose your protected health care information as required by law to a social services or other governmental agency authorized by law to receive such reports.
Health Oversight Activities: We may disclose protected health care information to a health oversight agency that is charged with responsibility for ensuring compliance with the rules of government programs.
Specialized Government Functions: We may disclose protected health care information to units of the government with special functions, such as the US military, under certain circumstances as required by law.
Law Enforcement Officials, Judicial and Administrative Proceedings: We may disclose protected health care information to police or other law enforcement officials. We also may disclose protected health information in judicial or administrative proceedings, such as in response to a subpoena.
Coroners or Medical Examiners: We may disclose protected health care information to a coroner or medical examiner as required by law.
Organ and Tissue Donation: We may disclose protected health care information to organizations that assist with organ, eye, or tissue donation, banking or transplant.
Health or Safety: We may disclose protected health care information to prevent a serious threat to your health and safety or the health of the public or another person.
Workers Compensation: We may disclose protected health care information as authorized by and to the extent necessary to comply with the laws relating to workers compensation or other similar programs or as required under laws relating to workplace injury and illness.
As required by law: We may disclose protected health care information when required to do so by any other law not already referred to in the preceding categories.
For any purpose other than the ones described above, we may only use or disclose your protected health information when you give us your written authorization.
Your rights regarding your health information.
Right to request access to your health information: You may request access to your medical record file and billing records maintained by us in order to inspect and request copies of the records. All requests for access must be made in writing. Under limited circumstances, we may deny you access to your records. If you would like to access your records, please obtain a record request form from your health care provider. If you request copies, we will charge you a reasonable fee for copies. We will also charge you for our postage costs, if you request that we mail the copies to you. If you are a parent or a legal guardian of a minor, certain portions of the minor’s medical record may not be accessible to you under California law.
Right to request Amendments to your health information: You have the right to request that we amend your health information maintained in your medical record file or billing records. If you wish to amend your records, please obtain an amendment request form from your health care provider. All requests for amendments must be in writing.
Right to revoke your authorization: You may revoke (take back) any written authorization obtained by us for the use and disclosure of your protected health information, except to the extent that we have taken action in reliance upon it. Your revocation must be in writing.
Right to request your information is provided to you: You may request, and we will try to accommodate any reasonable written request for you to receive protected health information by alternative means of communication or at different address or location.
Right to request restrictions on the use of your health information: You may request that we restrict the use or disclosure of your protected heath information. All requests for such restrictions must be in writing. While we will consider a request for additional restrictions carefully, we are not required to agree to a requested restriction and it is our offices general policy not to agree to such restrictions.
Right to change terms of this notice: We may change the terms of this notice at any time. If we change this notice, we may make the new notice terms effective for all protected health information that we hold, including any information created or received prior to issuing the new notice. If we change this notice, we will make the revised notice available upon request.