GRAHAM FAMILY DENTISTRY 
                                                                                                         NOTICE OF PRIVACY PRACTICES

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.

If you have any questions about this please contact our Privacy Officer, Cheri at 253-847-1964.

This Notice of Privacy Practices describes how we may use and disclose your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law.  It also describes your rights to access and control your protected health information. Protected health information is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

We are required to abide by the terms of this Notice of Privacy Practices.  We may change the terms of our notice, at any time.  The new notice will be effective for all protected health information that we maintain at that time.  Upon your request, we will provide you with any revised Notice of Privacy Practices. 

A. Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office who 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 for the operation of this office.

Following are a few examples of the types of uses and disclosures of your protected health information that we are permitted to make.

Treatment:  We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services.  This includes the coordination or management of your health care with another provider. For example, we would disclose your protected health information, as necessary, to a home health care agency that provides care to you or to other physicians who may be treating you, such as a physician to whom you have been referred. In addition, we may disclose your protected health information from time-to-time to another physician or health care provider (e.g., a specialist or laboratory) who are involved in your care.

Payment: Your protected health information will be used and disclosed to obtain payment for your health care services provided by us or by another provider.  This may include certain activities of your health insurance plan before it approves or pays for the health care services we recommend such as: making a determination of eligibility or coverage for insurance benefits, and reviewing services provided for medical necessity. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission. 

Health Care Operations: We may use or disclose your protected health information in order to support the business activities of this office. These activities include, but are not limited to, quality assessment activities, employee review oversight and training, licensing, and conducting or arranging for other business activities.

We will share your protected health information with third party “business associates” that perform various activities (for example, billing or transcription services) for our office.  Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.

We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you.  You may contact our office to request that these materials not be sent to you.

We may use or disclose your demographic information and the dates that you received treatment from your physician, as necessary, in order to contact you for fundraising activities supported by our office.  If you do not want to receive these materials, please contact our office.

Other Permitted and Required Uses and Disclosures That May Be Made Without Your Authorization or Opportunity to Agree or Object 

We may use or disclose your protected health information in the following situations without your authorization or providing you the opportunity to agree or object.  These situations include:

Required By Law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. The use or disclosure will be made in compliance with the law and will be limited to the relevant requirements of the law. You will be notified, if required by law, of any such uses or disclosures.

Public Health:  We may disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information. For example, a disclosure may be made for the purpose of preventing or controlling disease or injury.

Communicable Diseases:  We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health Oversight:  We may disclose protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, and inspections.  Oversight agencies seeking this information include government agencies that oversee the health care system and government benefit programs.

Abuse or Neglect:  We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect.  In addition, we may disclose your protected health information if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information.  In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Food and Drug Administration:  We may disclose your protected health information to a person or company required by the Food and Drug Administration for the purpose of quality, safety, or effectiveness of FDA-regulated products or activities including, to report adverse events, product defects and biologic deviations, for tracking to enable product recalls; to make repairs or replacements, or to conduct post marketing surveillance, as required.

Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized), or in certain conditions in response to a court order, subpoena, discovery request or other lawful process. 

Law Enforcement: We may also disclose protected health information, so long as applicable legal requirements are met, for law enforcement purposes. These law enforcement purposes include (1) legal processes and otherwise required by law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime occurs on our premises, and (6) medical emergency (not on our premises) and it is likely that a crime has occurred. 

Coroners, Funeral Directors, and Organ Donation: We may disclose protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the coroner or medical examiner to perform other duties authorized by law. We may also disclose protected health information to a funeral director to carry out their duties as authorized by law. Protected health information may be used and disclosed for cadaveric organ, eye or tissue donations.

Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information.

Criminal Activity: Consistent with applicable federal and state laws, we may disclose your protected health information, if we believe that the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public, or if it is necessary for law enforcement authorities to identify or apprehend an individual. 

Military Activity and National Security: When the appropriate conditions apply, we may use or disclose protected health information of individuals who are Armed Forces personnel (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign military authority if you are a member of that foreign military services. We may also disclose your protected health information to authorized federal officials for conducting national security and intelligence activities.

Workers’ Compensation: We may disclose your protected health information to the extent necessary to comply with workers’ compensation laws and other similar programs established by law.

Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.

Uses and Disclosures of Protected Health Information Based upon our Written Authorization

Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law as described below. You may revoke this authorization in writing at any time. If you revoke your authorization, we will no longer use or disclose your protected health information for the reasons covered by your written authorization. Please understand that we are unable to take back any disclosures already made with your authorization.

Other Permitted and Required Uses and Disclosures Providing You the Opportunity to Agree or Object

We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest.

Facility Directories: Unless you object, we will use and disclose in our facility directory your name, the location at which you are receiving care, your general condition (such as fair or stable), and your religious affiliation. All of this information, except religious affiliation, will be disclosed to people that ask for you by name.  Your religious affiliation will be only given to a member of the clergy.

Others Involved in Your Health Care or Payment for your Care: Unless you object, we may disclose to a member of your family, a relative, a close friend or any other person you identify, your protected health information that directly relates to that person’s involvement in your health care. If you are unable to agree or object, we may disclose information as necessary if we determine that it is in your best interest based on our professional judgment. We may use or disclose protected health information your location, general condition or death to notify a family member, personal representative or other person who is responsible for your care. We may use or disclose your protected health information to an authorized public or private entity to assist in disaster relief efforts.

B. Your rights in regard to your protected health  information and how to exercise your rights

You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you for so long as it is maintained by our office. You may obtain your medical record that contains medical and billing records and any other records that your physician and the office use for making decisions about you. As permitted by federal or state law, we may charge you a reasonable cost-based fee for access to your records.                               

Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and certain laboratory results subject to the Clinical Laboratory Improvements Amendments of 1988. Depending on the circumstances, a decision to deny access may be reviewable and you may have a right to have this decision reviewed. Your request for access must be in writing. Please contact our office if you have questions about access to your medical record. 

You have the right to request a restriction of your protected health information. This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or health care operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. 

This office is not required to agree to a restriction that you may request.  If this office agrees to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment.  With this in mind, please discuss any restriction you wish to request with your physician.  You may request a restriction by contacting our Privacy Officer, Cheri. 

You have the right to request to receive confidential communications from us by alternative means or location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact.  We will not request an explanation from you as to the basis for the request. Please make this request in writing to our office.

You may have the right to request an amendment of your protected health information.  This means you may request an amendment of protected health information about you in a designated record set for so long as we maintain this information.  In certain cases, we may deny your request for an amendment.  If we deny your request for amendment, you have the right to file a statement of disagreement with us; we may prepare a rebuttal to your statement and will provide you with a copy the rebuttal.  Please contact our office if you have questions about amending your medical record.  

You have the right to receive an accounting of certain disclosures of your protected health information. This right applies to disclosures for purposes other than treatment, payment or health care operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you if you authorized disclosures for a facility directory, to family members or friends, for notification purposes, for national security or intelligence, to law enforcement or correctional facilities. You have the right to receive information regarding these disclosures that occur after April 14, 2003, with certain exceptions, restrictions, and limitations. 

You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

C. Complaints

You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us.  You may file a complaint with us by notifying our office of your complaint.  We will not retaliate against you for filing a complaint. 

You may contact our office, Cheri at 253-847-1964 for further information about the complaint process. 

This notice was published and becomes effective on June 1, 2012.

                                                                                                  GRAHAM FAMILY DENTISTRY 
                                                                                                   21112 MERIDIAN AVE E
                                                                                                     GRAHAM, WA 98338 
                                                                                                              253-847-1964
It is our policy to provide individuals or their personal representatives with access to protected health information (PHI) in accordance with CFR 164.524

Individuals may access their PHI by contacting the Privacy officer, Graham Family Dentistry 21112 Meridian Ave E., Graham, WA 98338, Phone 253-847-1964.
Requests for access to PHI must be submitted in writing, provided that this office informs the individual of this requirement in advance, such as in our Notice of Privacy Practices. 45CFR 164.524(b)(1).
This office may charge a reasonable cost based fee for providing these records. The fees will only include the cost of supplies for and labor of copying, postage if the individual has requested that the information be mailed, and costs for preparing an explanation or summary of the information if agreed to by the individual. See 45CFR 164.524©(4).
This office will provide the individual with access to the PHI in the form or format requested by the individual if it is readily producible in such form or format; or, if not, in a readable hard copy form or such other form as agreed to by both parties. See 45CFR 164.524(c)(2).
This office typically takes between three (3) and five (5) calendar days to respond to a request for access. We can take up to 30 calendar days to respond to the request for access to PHI. If we need additional time beyond 30 days, we will notify the requester in writing of the extra time needed (up to no more than an additional 30 days) within the first 30 days in accordance with 45CFR 164.524(b)(2).
Any denial of access to PHI by this office will be in writing and provided to the requester pursuant to 45CFR 164.524(a)(1)-(4) and (d). If access is denied for any of the following reasons, the requester must be informed in writing of the right to have the denial reviewed in accordance with 45CFR 164.524(a)(3)-(4) and (d)(4):

• a licensed health care provider has determined that the access is likely to endanger the life or physical safety of the requesting individual or another person;
• the requested PHI references another person who is not a health care professional, and a licensed health care provider has determined that the requested access is likely to cause substantial harm to such other person; or
• the request for access was made by an individual’s personal representative and a licensed health care provider has determined that providing the access to such personal representative is reasonably likely to cause substantial harm to the individual or another person.  

21112 Meridian Ave E Graham, WA 98338
​253-847-1964

Graham Family Dentistry

21112 Meridian Ave E
Graham, WA 98338

​253-847-1964