HIPAA Patient Policy

Consent For Use And Disclosure Of Health Information

Supremia Dentistry, Dr. Edmond W. Suh, DDS


Purpose of Consent: The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal program that requires all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPAA” provides penalties for covered entities that misuse personal health information. By signing this form, you will consent for us to use and disclosure of your protected health information to carry out treatment, payment activities (including filing insurance), and health operations.

As required by “HIPAA”, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

We may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operations.

  • TREATMENT means providing coordination, or managing health care and related services by one or more health care providers. An example of this would include a physical examination.
  • PRESCRIPTION means obtaining any information that may be needed from the pharmacy to help provide me with the proper care. An example of this would be obtaining past prescriptions and dates they were filled.
  • PAYMENT means such activities as obtaining reimbursement for services, confirming coverage, billing or collection, activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.
  • HEALTH CARE OPERATIONS include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, costmanagement analysis and customer service. An example would be an internal quality assessment review.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

You have the following rights with respect to your protected health information (PHI), which you can exercise by presenting a written request to the Privacy Officer:

  • The right to request restrictions on certain uses and disclosures of PHI, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
  • The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
  • The right to inspect and copy your protected health information.
  • The right to amend your protected health information.
  • The right to receive an accounting of disclosures of protected health information.
  • The right to obtain a paper copy of this notice from us upon request.

We are required by law to maintain the privacy of your PHI and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

This notice is effective as of 4/14/2010 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.

You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with our office, or with the Department of Health & Human Services, Office of Civil Rights about violations of the provisions of this notice or the policies and procedures of our office. We won’t retaliate against you for filing a complaint.

Privacy Policy for 10DLC Compliant: Our website adheres to a privacy policy that explicitly states we do not share consumer information with third parties for marketing purposes. We are committed to safeguarding the privacy and security of your personal details, utilizing them solely for the intended purposes outlined in our privacy policy. For further details or inquiries about how your information is handled, please refer to our privacy policy or reach out to us directly.

Contact Supremia Dentistry

Schedule a consultation with Supremia Dentistry