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.
This is your Health Information Privacy Notice from Dr. Garza's practice. Please read it
carefully. You have received this notice because you may be a ptiant of ours or communicate
via our website with our practice. Dr. Garza and each member of his practice (an "Affiliate")
strongly believe in protecting the confidentiality and security of information we collect about
you. This notice refers to Dr Garza by using the terms "us," "we," or "our."
This notice describes how we protect the personal health information we have about you which
relates to your dental treatments ("Personal Health Information"), and how we may use and
disclose this information. Personal Health Information includes individually identifiable
information which relates to your past, present or future health, treatment or payment for
health care services. This notice also describes your rights with respect to the Personal Health
Information and how you can exercise those rights.
We are required to provide this Notice to you by the Health Insurance Portability and
Accountability Act ("HIPAA"). For additional information regarding our HIPAA Medical Information
We are required by law to:
Maintain the privacy of your Personal Health Information;
provide you this notice of our legal duties and privacy practices with respect to your Personal
Health Information; and follow the terms of this notice.
We protect your Personal Health Information from inappropriate use or disclosure. Our employees,
and those of companies that help us service your Dental Insurance, are required to comply with
our requirements that protect the confidentiality of Personal Health Information. They may look
at your Personal Health Information only when there is an appropriate reason to do so, such as
to administer our products or services.
We will not disclose your Personal Health Information to any other company for their use in
marketing their products to you. However, as described below, we will use and disclose Personal
Health Information about you for business purposes relating to your Dental Insurance coverage and
your dental treatment.
The main reasons for which we may use and may disclose your Personal Health Information are to
evaluate and process any requests for coverage and claims for benefits you may make or in
connection with other health-related benefits or services that may be of interest to you. The
following describe these and other uses and disclosures, together with some examples.
For Payment: We may use and disclose Personal Health Information to pay for benefits under
your Dental Insurance coverage. For example, we may review Personal Health Information contained
on claims to reimburse providers for services rendered. We may also disclose Personal Health
Information to other insurance carriers to coordinate benefits with respect to a particular claim.
Additionally, we may disclose Personal Health Information to a health plan or an administrator of
an employee welfare benefit plan for various payment-related functions, such as eligibility
determination, audit and review or to assist you with your inquiries or disputes.
For Health Care Operations: We may also use and disclose Personal Health Information for our
insurance operations. These purposes include evaluating a request for Dental Insurance
products or services, administering those products or services, and processing transactions
requested by you. We may also disclose Personal Health Information to Affiliates, and to business
associates outside of the our practice of companies, if they need to receive Personal Health
Information to provide a service to us and will agree to abide by specific HIPAA rules relating
to the protection of Personal Health Information. Examples of business associates are: billing
companies, data processing companies, or companies that provide general administrative services.
Personal Health Information may be disclosed to reinsurers for underwriting, audit or claim
review reasons. Personal Health Information may also be disclosed as part of a potential merger or
acquisition involving our business in order to make an informed business decision regarding any
such prospective transaction.
Where Required by Law or for Public Health Activities: We disclose Personal Health Information
when required by federal, state or local law. Examples of such mandatory disclosures include
notifying state or local health authorities regarding particular communicable diseases, or
providing Personal Health Information to a governmental agency or regulator with health care
oversight responsibilities. We may also release Personal Health Information to a coroner or
medical examiner to assist in identifying a deceased individual or to determine the cause of death.
To Avert a Serious Threat to Health or Safety: We may disclose Personal Health Information to
avert a serious threat to someone's health or safety. We may also disclose Personal Health
Information to federal, state or local agencies engaged in disaster relief as well as to
private disaster relief or disaster assistance agencies to allow such entities to carry out their
responsibilities in specific disaster situations.
For Health-Related Benefits or Services: We may use Personal Health Information to provide you
with information about benefits available to you under your current coverage or policy and, in
limited situations, about health-related products or services that may be of interest to you.
For Law Enforcement or Specific Government Functions: We may disclose Personal Health
Information in response to a request by a law enforcement official made through a court order,
subpoena, warrant, summons or similar process. We may disclose Personal Health Information about
you to federal officials for intelligence, counterintelligence, and other national security
activities authorized by law.
When Requested as Part of a Regulatory or Legal Proceeding: If you or your estate are involved
in a lawsuit or a dispute, we may disclose Personal Health Information about you in response to
a court or administrative order. We may also disclose Personal Health Information about you in
response to a subpoena, discovery request, or other lawful process by someone else involved in
the dispute, but only if efforts have been made to tell you about the request or to obtain an
order protecting the Personal Health Information requested. We may disclose Personal Health
Information to any governmental agency or regulator with whom you have filed a complaint or as
part of a regulatory agency examination.
Other Uses of Personal Health Information: Other uses and disclosures of Personal Health
Information not covered by this notice and permitted by the laws that apply to us will be made
only with your written authorization or that of your legal representative. If we are authorized
to use or disclose Personal Health Information about you, you or your legally authorized
representative may revoke that authorization, in writing, at any time, except to the extent that
we have taken action relying on the authorization. You should understand that we will not be able
to take back any disclosures we have already made with authorization.
Your Rights Regarding Personal Health Information We Maintain About You
The following are your various rights as a consumer under HIPAA concerning your Personal Health
Information. Should you have questions about a specific right, please write to us at the
location listed in our discussion of that right.
Right to Inspect and Copy Your Personal Health Information: In most cases, you have the right
to inspect and obtain a copy of the Personal Health Information that we maintain about you. To
receive a copy of your Personal Health Information, you may be charged a fee for the costs of
copying, mailing or other supplies associated with your request. However, certain types of
Personal Health Information will not be made available for inspection and copying. This
includes Personal Health Information collected by us in connection with, or in reasonable
anticipation of any claim or legal proceeding. In very limited circumstances we may deny your
request to inspect and obtain a copy of your Personal Health Information. If we do, you may
request that the denial be reviewed. The review will be conducted by an individual chosen by us
who was not involved in the original decision to deny your request. We will comply with the
outcome of that review.
Right to Amend Your Personal Health Information: If you believe that your Personal Health
Information is incorrect or that an important part of it is missing, you have the right to ask
us to amend your Personal Health Information while it is kept by or for us. We may deny your
request if it is not in writing or does not include a reason that supports the request. In
addition, we may deny your request if you ask us to amend Personal Health Information that:
is accurate and complete;
was not created by us, unless the person or entity that created the Personal Health
Information is no longer available to make the amendment;
is not part of the Personal Health Information kept by or for us;
or is not part of the Personal Health Information which you would be permitted to inspect and copy.
Right to a List of Disclosures: You have the right to request a list of the disclosures we
have made of Personal Health Information about you. This list will not include disclosures made
for treatment, payment, health care operations, for purposes of national security, made to law
enforcement or to corrections personnel or made pursuant to your authorization or made directly
to you. To request this list, you must submit your request in writing to click here. Your
request must state the time period from which you want to receive a list of disclosures. The
time period may not be longer than six years and may not include dates before April 14, 2003.
Your request should indicate in what form you want the list (for example, on paper or
electronically). The first list you request within a 12-month period will be free. We may charge
you for responding to any additional requests. We will notify you of the cost involved and you may
choose to withdraw or modify your request at that time before any costs are incurred.
Right to Request Restrictions: You have the right to request a restriction or limitation on
Personal Health Information we use or disclose about you for treatment, payment or health care
operations, or that we disclose to someone who may be involved in your care or payment for your
care, like a family member or friend. While we will consider your request, we are not required
to agree to it. If we do agree to it, we will comply with your request. To request a restriction,
you must make your request in writing to click here. In your request, you must tell us (1) what
information you want to limit; (2) whether you want to limit our use, disclosure or both; and
(3) to whom you want the limits to apply (for example, disclosures to your spouse or parent).
We will not agree to restrictions on Personal Health Information uses or disclosures that are
legally required, or which are necessary to administer our business.
Right to Request Confidential Communications: You have the right to request that we communicate
with you about Personal Health Information in a certain way or at a certain location if you tell
us that communication in another manner may endanger you. For example, you can ask that we only
contact you at work or by mail. To request confidential communications, you must make your request
in writing to click here. We will accommodate all reasonable requests.
Right to File a Complaint: If you believe your privacy rights have been violated, you may file
a complaint with us or with the Secretary of the Department of Health and Human Services.
Changes to This Notice: We reserve the right to change the terms of this notice at any time.
We reserve the right to make the revised or changed notice effective for Personal Health
Information we already have about you as well as any Personal Health Information we receive in the
future. The effective date of this notice and any revised or changed notice may be found on the
last page, on the bottom right hand corner of the notice.
Further Information: You may have additional rights under other applicable laws. For
privacy policies, please contact us.