Dr. Phil Shay, D.D.S. M.S.
  • Tel: 212-808-0709

SUMMARY OF NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACFESS 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 full complete 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 Notice.

NOTICE OF PRIVACY PRACTICES

You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting us. You may contact our office by calling 212-808-0709 and requesting that a revised copy be sent to you in the mail, or asking for one at the time of your next appointment.


USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION (HEREOUT REFERRED TO AS PHI)

TREATMENT

Your protected health information may be used and disclosed by your dentist, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of the dental practice.

We will use and disclose your PHI to manage your dental care and any related services. This may include the coordination of your health care with a third party. We will also disclose PHI to other dentists who may be treating you such as a specialist to whom you have been referred to ensure that the dentist has the necessary information to diagnose or treat you and receive payment. We may also disclose your PHI to another dentist or health care provider (specialist, laboratory, study club) who, at the request of your dentist, becomes involved in your care by providing assistance with your diagnosis or treatment or research support.

PAYMENT

We may use and disclose your PHI to obtain payment for services we provided to you. This may include PHI to satisfy requests from insurance plans determining eligibility or coverage for benefits and reviewing services provided to you for medical necessity, and undertaking utilization review activities. We may also disclose PHI through billing statements that are sent to your home under the name and address we have on file as primary guarantor of account.

HEALTHCARE OPERATIONS

We may use and disclose your PHI 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 and technology maintenance.

We may use or disclose your PHI to discuss topics related to treatment (for example: evaluation of study models, radiographs, laboratory results or oral hygiene practices) with patients and /or parents in open treatment areas, X-ray, and reception areas. Your name may be visible on a schedule posted in treatment areas and your name may be disclosed when greeting you or inviting you into a treatment area.

We may use or disclose your PHI to provide you with appointment reminders (such as voicemail messages, postcards, or letters and informational newsletters.) Others who have access to your voice mailboxes may hear these messages. Also, calls being made from our office may be overheard by others in the area. Messages of appointments may also be left with others at a contact number that you provide for us. 

TO YOUR FAMILY AND FRIENDS

We must disclose your health information to you. We may disclose your PHI to a family member, friend or other person to the extent necessary to help with your healthcare or with payments for your healthcare, but only if you agree that we may do so.

PERSONS INVOLVED IN YOUR CARE

We may use or disclose PHI 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 your PHI, 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.

MARKETING HEALTH RELATED 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 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 correctional institution or law enforcement officials having lawful custody of PHI of inmate or patient under certain circumstances.

YOUR AUTHORIZATION

In addition to our use of you PHI for treatment, payment or healthcare operations, you may give us written authorization to use your PHI 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 PHI for any reason except those described in this notice.


PATIENT RIGHTS

ACCESS

In addition to our use of you PHI for treatment, payment or healthcare operations, you may give us written authorization to use your PHI 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 PHI for any reason except those described in this notice.

DISCLOSURE ACCOUNTING

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.

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 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 how payments will be handled under the alternative means or location you request.

AMMENDMENT

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 Web site or by electronic mail (e-mail), you are entitled to receive this Notice in it's entirety 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 also may submit a written complaint to he 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. 

REVOCATION OF CONSENT

_______I do not revoke my Consent for your use and disclosure of my protected health information for treatment, payment activities, and healthcare operations.

_______I understand that revocation of my Consent will not affect any action you took in reliance on my Consent before you received this written Notice of Revocation. I also understand that you may decline to treat or to continue to treat me after I have revoked my Consent.

You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed below. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

ATTENTION: Office Manager
SHAY DENTAL ASSOCIATES
30 E. 60th Street (Park-Madison)
New York, NY 10022