THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED, DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT.
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 on 1/1/2022 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 changes in our privacy practices and 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 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 the Notice, please contact us using the information listed at the end of this Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For Example:
TREATMENT: We may use and disclose your health information to a physician 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.
HEALTHCARE OPERATIONS: 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, conduction training programs, accreditation, certification, licensing, or credentialing activities.
YOUR AUTHORIZATION: In addition to our use of your health information for treatment, payment, or healthcare operations, you may give us written authorization to use your health information 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 this Notice.
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 another person, to the extent necessary to help 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 that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practices 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.
MARKETING HEALTH-RELATED SERVICES: We will not use your health information for marketing communications without your written authorization.
ONLINE: I expect Holistic Health Dental Solutions will not speak or write about me publicly in any negative fashion. I agree to do the same. I understand and agree the name and other proprietary information about Holistic Health Dental Solutions is valuable intellectual property protected by law. I understand and agree that disparaging Holistic Health Dental Solutions, it’s dentist’s or staff in any manner, through print, broadcast or the Internet, including social media, will damage the value of this intellectual property. Therefore, I hereby give Holistic Health Dental Solutions and its representatives the non-revoke-able right and power to remove or have removed any and all disparaging or negative information I’ve said, written or published about Holistic Health Dental Solutions or its employees or agents from any media.
REQUIRED BY LAW: We may use or disclose your health information if 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, 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, safety, or safety of others.
NATIONAL SECURITY: 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 a correctional institution having custody of protected health information of inmate or patient under certain circumstances.
APPOINTMENT REMINDERS: We may use or disclose some of your health information to provide you with appointment reminders (such as texts, 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 copies, we will charge you 10¢ for each page, $10 per hour for staff time to locate and copy your health information, plus postage if you want the copies mailed to you. 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 at the end of this Notice for a full explanation of our fee structure.)
DISCLOSURE ACCOUNTING: You have the right to receive a list of instances in which we or our business associates have 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 13, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for the responding to the additional requests.
RESTRICTION: You 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 an emergency.)
ALTERNATIVE COMMUNICATIONS: 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 how payments will be handled under the alternative means or location you request.
AMENDMENT: You 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.
ELECTRONIC NOTICE: If you receive this Notice on our website or by electronic mail (e-mail), you are entitled to receive this Notice in written form.
QUESTIONS AND ISSUES:
If you have any issue with Holistic Health Dental Solutions the fastest course of action to solve any issue is to call the Team Leader or Dr. Ben-Roohi directly. Your calls are always welcome and they will always be returned.
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 potentially violated your privacy rights, or you disagree with a decision we have made about access to your health information, or in response to a request you have made to amend or restrict the use or disclosure of your health information we ask you to immediately bring your concern to our attention using the contact information listed at the end of this Notice. You also may submit your issue to the U.S. Department of Health and Human Services. We will provide you with the address upon request.
We fully 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.
Holistic Health Dental Solutions
1811 Wilshire Blvd., Suite 203
Santa Monica, CA 90403