Your Information. Your Rights. Our Responsibilities
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.
We reserve the right to change this Notice. We reserve the right to make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future.
Who Will Follow This Notice?
This Notice describes Skyline Smiles Privacy Practices and that of any workforce member authorized to create medical information referred to as Protected Health Information (PHI) which may be used for purposes such as Treatment, Payment, and Healthcare Operations. These workforce members may include:
- All departments and units of Skyline Smiles.
- Any member of a volunteer group.
- All employees, staff, and other Skyline Smiles personnel.
- Any entity providing services under Skyline Smiles direction and control will follow the terms of this notice. In addition, these entities, sites, and locations may share medical information with each other for Treatment, Payment, or Healthcare Operational purposes described in this Notice.
Our Pledge Regarding Medical Information
We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. This Notice applies to all of the records of your care generated or maintained by Skyline Smiles.
We are required by law to:
- Make sure that medical information that identifies you is kept private.
- Give you this Notice of our legal duties and privacy practices with respect to medical information about you.
- Follow the terms of the Notice that is currently in effect.
Uses and Disclosures of Health Information
- Treatment: We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, health care students, or other Skyline Smiles personnel who are involved in taking care of you. We also may disclose medical information about you to people outside of Skyline Smiles who may be involved in your medical care.
- Payment: We may use and disclose medical information about you so that the treatment and services you receive at the Skyline Smiles may be billed and payment may be collected from you, an insurance company, or a third party. We may also tell your health plan about a prescribed treatment to obtain prior approval or to determine whether your plan will cover the treatment.
- Healthcare Operations: We may use and disclose medical information about you for practice operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performances, conducting training programs, accreditation, certification, licensing or credentialing activities.
- Appointment Reminders: We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at Skyline Smiles.
- Treatment Alternatives: We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
- Health-Related Benefits and Services: We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
- Fundraising Activities: We may use information about you to contact you in an effort to raise money for Skyline Smiles and its operations. We will not use your health information for fundraising activities without your written consent.
- Authorizations Required: We will not use your protected health information for any purposes not specifically allowed by Federal or State laws or regulations without your written authorization; this includes uses of your PHI for marketing or sales activities.
- Emergencies: We may use or disclose your medical information if you need emergency treatment or if we are required by law to treat you but are unable to obtain your consent. If this happens, we will try to obtain your consent as soon as we reasonably can after we treat you.
- Psychotherapy Notes: Psychotherapy notes are accorded strict protections under several laws and regulations. Therefore, we will disclose psychotherapy notes only upon your written authorization with limited exceptions.
- Communication Barriers: We may use and disclose your health information if we are unable to obtain your consent because of substantial communication barriers, and we believe you would want us to treat you if we could communicate with you.
- Provider Directory: We may include certain limited information about you in the practice directory while you are a patient at Skyline Smiles.
- Individuals Involved in Your Care or Payment of Your Care: We may release medical information about you to a friend or family member who is involved in your medical care and we may also give information to someone who helps pay for your care, unless you object in writing and ask us not to provide this information to specific individuals. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.
- Research: Under certain circumstances, we may use and disclose medical information about you for research purposes. We will almost always generally ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at Skyline Smiles.
- As Required By Law: We will disclose medical information about you when required to do so by federal, state or local law.
- To Avert a Serious Threat to Health or Safety: We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.
- Email Use: Email will only be used following Skyline Smiles current policies and practices and with your permission. The use of secured, encrypted email is encouraged.
- Other Special Circumstances Include:
- Organ and Tissue Donation
- Military and Veterans
- Workers’ Compensation
- Public Health Risks
- Health Oversight Activities
- Lawsuits and Disputes
- Law Enforcement
- Coroners, Medical Examiners, and Funeral Directors
- National Security and Intelligence Activities
- Protective Services
- Inmates
Your Rights Regarding Your Medical Information
- Right to Access: You have the right to access, inspect and copy the medical information that may be used to make decisions about your care, with a few exceptions. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. We may deny your request to inspect and copy medical information in certain very limited circumstances. If you are denied access to medical information, in some cases, you may request that the denial be reviewed.
- Right to Amend: You have the right to request an amendment for as long as the information is kept by or for Skyline Smiles. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information under certain circumstances.
- Right to an Accounting of Disclosures: You have the right to request an ‘Accounting of Disclosures’. This is a list of the disclosures we made of medical information about you. Your request must state a time period which 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 accounting (for example, on paper or electronically, if available). The first accounting you request within a 12 month period will be complimentary. For additional lists, we may charge you for the costs of providing the list.
- Right to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for payment or healthcare operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. In your request, you must tell us what information you want to limit, whether you want to limit our use, disclosure or both, and to whom you want the limits to apply (for example, disclosures to your spouse). We are not required to agree to these types of requests. We will not comply with any requests to restrict use or access of your medical information for treatment purposes. You also have the right to restrict use and disclosure of your medical information about a service or item for which you have paid out of pocket, for payment (i.e. health plans) and operational (but not treatment) purposes, if you have completely paid your bill for this item or service. We will not accept your request for this type of restriction until you have completely paid your bill (zero balance) for this item or service. We are not required to notify other healthcare providers of these restrictions, that is your responsibility.
- Right to Receive Notice of a Breach: We are required to notify you by first class mail or by email (if you have indicated a preference to receive information by email), of any breaches of Unsecured Protected Health Information as soon as possible, but in any event, no later than 60 days following the discovery of the breach.
- Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.
- Right to a Paper Copy of This Notice: You have the right to a paper copy of this Notice. You may ask us to give you a copy of this Notice at any time.
To exercise the above rights, please contact the Skyline Smiles of West Loop office listed at the bottom of this Notice to obtain a copy of the relevant form you will need to complete to make your request.
Questions and Concerns
If you have any questions about this Notice of Privacy Practices, please contact:
Privacy Contact: Skyline Smiles of West Loop
Phone Number: 312-759-1120
If you believe your privacy rights have been violated, you may file a complaint with Skyline Smiles or with the Secretary of the Department of Health and Human Services. To file a complaint with the Provider, contact the individual listed on the first page of this Notice. All complaints must be submitted in writing. We support your right to maintain the privacy of your health information. We will not retaliate in any way if you choose to file a complaint
