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PATIENT PRIVACY POLICY

PATIENT PRIVACY POLICY

Notice of Privacy Practices for Protected Health Information

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.

With your consent, San Fernando Valley Oral Surgery&Implant is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care and treatment. It also includes billing documents for those services.

Examples of uses of your health information for treatment purposes:

A nurse obtains treatment information about you and records it in a health record. During the course of your treatment, the doctor determines a need to consult with another specialist in the area. The doctor will share the information with such specialist and obtain input.

Example of use of your health information for payment purposes:

We submit a request for payment to your health insurance company. The health insurance company requests information from us regarding medical care given. We will provide information to them about you and the care given.

Example of use of your information for health care operations:

We obtain services from our insurers or other business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guideline development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such insurers or other business associates as necessary to obtain these services.

Your Health Information Rights

The health and billing records we maintain are the physical property of San Fernando Valley Oral Surgery&Implant. The information in it, however, belongs to you. You have a right to:

Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office. We are not required to grant the request, but we will try to reasonably comply with any request;

Request that you be allowed to inspect and copy your health record and billing record you may exercise this right by delivering the request in writing to our office;

Appeal a denial of access to your protected health information except in certain circumstances;

Request that your health care record be amended to correct incomplete or incorrect information by delivering and written request to our office;

File a statement of disagreement if your amendment is denied, and require that a request for amendment and any denial be attached in all future disclosures of your protected health information;

Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our office. An accounting will not include internal uses of information for treatment, payment, or operations, disclosures made to you or made at your request, or disclosures made to family members or friends in the course of providing care;

Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office; and

Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office.

If you want to exercise any of the above rights, please contact the Practice Administrator at San Fernando Valley Oral Surgery&Implant, 2600 S. 56th Street #A, Lincoln, NE 68506, Nebraska Oral and Facial Surgery - 402-327-9400. He will provide you with assistance on the steps to take to exercise your rights.

Our Responsibilities

San Fernando Valley Oral Surgery&Implant is required to:

Maintain the privacy of your health information as required by law;

Provide you with a notice of our duties and privacy practices as to the information we collect and maintain about you;

Abide by the terms of this Notice;

Notify you if we cannot accommodate a request restriction or request; and Accommodate your reasonable requests regarding methods to communicate health information to you.

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by coming to our office or calling and requesting a copy.

To Request Information or File a Complaint

If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact the Practice Administrator at San Fernando Valley Oral Surgery&Implant: 402-327-9400.

Additionally, if you believe your privacy rights have been violated, you may file a written complaint to our office by delivering the written complaint to the Practice Administrator, San Fernando Valley Oral Surgery&Implant, 2600 S. 56th Street #A, Lincoln, NE 68506. You may also file a complaint by mailing it or e-mailing it to Health and Human Services to:

Frank Campbell, Regional Manager
Office for Civil Rights
U.S. Department of Health and Human Services
601 East 12th Street Room 353
Kansas City, MO 64106

Tel: 800-368-1019
Fax: 816-426-3686
TDD: 800-537-7697
[email protected]

We cannot, and will not, require you to waive the right to file a complaint with Health and Human Services (HHS) as a condition of receiving treatment from San Fernando Valley Oral Surgery&Implant.

We cannot, and will not, retaliate against you for filing a complaint with HHS.

FINANCIAL INFORMATION

FINANCIAL INFORMATION

San Fernando Valley Oral Surgery&Implant delivers the finest care at the most reasonable cost to our patients. Payment is expected at the time service is rendered unless prior arrangements have been made. If you have questions regarding your account, please contact us at 818 698 3319. We look forward to working with you to maximize your insurance benefits.

Dental Insurance Networks

Please refer to the Insurance page regarding Dental Insurance Networks and Medical Insurance Networks for which we are a Preferred Provider.

Payment

For your convenience, we accept the following forms of payment:

Cash
Personal check
Debit card
Electronic check
Visa
MasterCard
Discover
American Express.

We also offer alternative financing and payment options:

CareCredit
The Lending Club

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