This notice describes how health information about you may be used
and disclosed and how you can get access to this information.
Please review it carefully. The privacy of your health information
is important to us.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of
your health information. We are also required to give you this Notice about our privacy
practices, our legal duties, and your rights concerning your health information. We must
follow the privacy practices that are described in this Notice while it is in effect. This
Notice takes effect April 14, 2003, and will remain in effect until we replace it.
We reserve the right to change
our privacy practices and the terms of this Notice at any time, provided such changes are
permitted by applicable law. We reserve the right to make the changes in our privacy
practices and the new terms of our Notice effective for all health information that we
maintain, including health information we created or received before we made the changes.
Before we make a significant change in our privacy practices, we will change this Notice
and make the new Notice available upon request.
You may request a copy of our
Notice at any time. For more information about our privacy practices, or for additional
copies of this Notice, please contact us using the information listed at the end of this
USES AND DISCLOSURES OF
We use and disclose health information about you for treatment, payment, and
healthcare operations. For example:
may use or disclose your health information to a physician, dentist, or other healthcare
provider providing treatment to you.
Payment: We may
use and disclose your health information to obtain payment for services we provide to you.
We may use and disclose your health information in connection with our healthcare
operations. Healthcare operations include quality assessment and improvement activities,
reviewing the competence or qualifications of healthcare professionals, evaluating
practitioner and provider performance, conducting training programs, accreditation,
certification, licensing or credentialing activities.
In addition to our use of your health information for treatment, payment or healthcare
operations, you may give use written authorization to use your health information or to
disclose it to anyone for any purpose. If you give us an authorization, you may revoke it
in writing at any time. Your revocation will not affect any use or disclosures permitted
by your authorization while it was in effect. Unless you give us a written authorization,
we cannot use or disclose your health information for any reason except those described in
To Your Family and
Friends: We must disclose your health information to you, as described in the
Patient Rights section of this Notice. We may disclose your health information to a family
member, friend or other person to the extent necessary to health with your healthcare or
with payment for your healthcare, but only if you agree that we may do so.
Persons Involved in Care:
We may use or disclose health information to notify, or assist in the notification of
(including identifying or locating) a family member, your personal representative or
another person responsible for your care, of your location, your general condition, or
death. If you are present, then prior to use or disclosure of your health information, we
will provide you with an opportunity to object to such uses or disclosures. In the event
of your incapacity or emergency circumstances, we will disclose health information based
on a determination using our professional judgment disclosing only health information that
is directly relevant to the person's involvement in your healthcare. We will also use our
professional judgment and our experience with common practice to make reasonable
inferences of your best interest in allowing a person to pick up filled prescriptions,
medical supplies, x-rays, or other similar forms of health information.
Services: We will not use your health information for marketing communications
without your written authorization.
Required by Law:
We may use or disclose your health information when we are required to do so by law.
Abuse or Neglect:
We may disclose your health information to appropriate authorities if we reasonably
believe that you are a possible victim of abuse, neglect, or domestic violence or the
possible victim of other crimes. We may disclose your health information to the extent
necessary to avert a serious threat to your health or safety or the health or safety of
We may disclose to military authorities the health information of Armed Forces personnel
under certain circumstances. We may disclose to authorized federal officials health
information required for lawful intelligence, counterintelligence, and other national
security activities. We may disclose to correctional institution or law enforcement
official having lawful custody of protected health information of inmate or patient under
We may use or disclose your health information to provide you with appointment reminders
(such as voicemail messages, postcards, or letters).
Access: You have the right to look at or get copies of your health information,
with limited exceptions. You may request that we provide copies in a format other than
photocopies. We will use the format you request unless we cannot practicably do so. (You
must make a request in writing to obtain access to your health information. You may obtain
a form to request access by using the contact information listed at the end of this
Notice. We will charge you a reasonable cost-based fee for expenses such as copies and
staff time. You may also request access by sending us a letter to the address at the end
of this Notice. If you request an alternative format, we will charge a cost-based fee for
providing your health information in that format. If you prefer, we will prepare a summary
or an explanation of your health information for a fee. Contact us using the information
listed at the end of this Notice for a full explanation of our fee structure.)
You have the right to receive a list of instances in which we or our business associates
disclosed your health information for purposes, other than treatment, payment, healthcare
operations and certain other activities, for the last 6 years, but not before April 14,
2003. If you request this accounting more than once in a 12-month period, we may charge
you a reasonable, cost-based fee for responding to these additional requests.
have the right to request that we place additional restrictions on our use or disclosure
of your health information. We are not required to agree to these additional restrictions,
but if we do, we will abide by our agreement (except in any emergency).
Communication: You have the right to request that we communicate with you about
your health information by alternative means or to alternative locations. (You must make
your request in writing.) Your request must specify the alternative means or location, and
provide satisfactory explanation of how payments will be handled under the alternative
means or location you request.
have the right to request that we amend your health information. (Your request must be in
writing, and it must explain why the information should be amended.) We may deny your
request under certain circumstances.
If you receive this Notice on our Web site or by electronic mail (e-mail), you are
entitled to receive this Notice in written form.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or
concerns, please contact us.
If you are concerned that we may
have violated your privacy rights, or you disagree with a decision we made about access to
your health information or in response to a request you made to amend or restrict the use
or disclosure of your health information or to have us communicate with you by alternative
means or at alternative locations, you may complain to us using the contact information
listed at the end of this Notice. You may also submit a written complaint to the U.S.
Department of Health and Human Services. We will provide you with the address to file your
complaint with the U.S. Department of Health and Human Services upon request.
We support your right to the
privacy of your health information. We will not retaliate in any way if you choose to file
a complaint with us or with the U.S. Department of Health and Human Services.
Attention: Privacy Officer
Robert J. Farbman, D.D.S., P.A.
1716 University Drive
Coral Springs, FL 33071
Fax: (954) 753-5333