Notice of Privacy Practices

We use and disclose health information about you for treatment, payment and health care operations. For example:

Treatment

We may use or disclose your health information to another dentist or other health care providers providing treatment that we do not provide. We may also share your health information with a pharmacist in order to provide you with a prescription or with a laboratory that performs tests or fabricates dental prostheses or orthodontic appliances.

Payment

We may use and disclose your health information to obtain payment for services we provide to you, unless you request that we restrict such disclosure to your health plan when you have paid out-of-pocket and in full for services rendered.

Health Care Operations

We may use and disclose your health information in connection with our health care operations, for example in sending appointment reminders. Other health care operations include but are not limited to quality assessment and improvement activities, reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. The California Confidentiality of Medical Information Act does limit the types of health care operations in which we can use or disclose your health information without your authorization. For example, if the dental practice is sold or merged, the new owner will seek permission to use your information to continue to treat you. Your authorization also is required if a credit or collection agency seeks your health information.

We may use business associates to conduct the above transactions.

We may also use and disclose your health information if required by law or for public health, benefit and safety purposes. For example:

Public Health and Safety

We may disclose your health information to a public health authority as part of lawful activities to prevent or control disease, injuries and disabilities and to the U.S. Food and Drug Administration to report safety issues with drugs and medical devices. We may disclose your health information to appropriate authorities if we reasonably believe that you are a 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.

Government Oversight

We may disclose your health information to government regulatory agencies, such as the Dental Board of California or the U.S. Department of Health and Human Services, to carry out their legal responsibilities in investigations, inspections, audits, enforcement and licensing.

Law Enforcement, Coroners and Legal Proceedings

We may disclose your health information to a law enforcement agency, coroner or medical examiner for official purposes such as identifying an individual or reporting crimes. We may be compelled to disclose your health information in response to a subpoena, court order, discovery request or other legal process. We may disclose to correctional institutions or law enforcement officials having lawful custody of protected health information of inmates or patients under certain circumstances.

Workers’ Compensation

We may disclose your health information to the extent permitted for workers’ compensation.

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.

Your Authorization

You may give us written authorization to use your health information 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 is in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those permitted uses described in this notice.

We may request your authorization to use your name, image or testimonial in our social media platforms and marketing efforts.

We may request your authorization to release your insurance information to another healthcare provider.

We may use and disclose your health information in the following circumstances:

To Family, Friends and Persons Involved in Your 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 your 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 based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your health care. 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, aligners, X-rays or other similar forms of health information.

You have the right to request restrictions on disclosure to family members, other relatives, close personal friends or any other person identified by you.

Marketing Health-Related Services

We may contact you about products or services related to your treatment, case management or care coordination or to propose other treatments or health-related benefits and services in which you may be interested. We may also encourage you to purchase a product or service when you visit our office. If you are currently an enrollee of a dental plan, we may receive payment for communications to you in relation to our provision, coordination or management of your dental care, including our coordination or management of your health care with a third party, our consultation with other health care providers relating to your care or if we refer you for health care. We will not otherwise use or disclose your health information for marketing purposes without your written authorization. We will disclose whether we receive payments for marketing activity you have authorized.

Change of Ownership

If this dental practice is sold or merged with another practice or organization, your health records will become the property of the new owner. Your information will be used to notify you of the change and the new owner may seek to obtain your permission to use your information to continue to treat you. You may request that copies of your health information be transferred to another dental practice.

Research

Your health information may be disclosed to researchers for research purposes. In this situation, written authorization is not required if approved by an Institutional Review Board or privacy board.

Fundraising

We may use or disclose demographic information and dates of treatment in order to contact you for fundraising activities. If you no longer wish to receive these communications, notify us at the contact information provided below and we will stop sending further fundraising information.

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 contacting our office. 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. If you request copies, there may be a charge for time spent. If you request an alternate 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. California law requires you be provided with access to your health information within 15 days. Contact us for a full explanation of our fee structure.

Disclosure Accounting

You have a right to receive a list of instances in which we disclosed your health information for purposes other than treatment, payment, health care operations and certain other activities for the last six years. 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 emergency). In the event you pay out-of-pocket and in full for services rendered, you may request that we not share your health information with your health plan. We must agree to this request.

Alternative Communication

You have the right to request that we communicate with you about your health information by alternative means or to send it to an alternative location. You must make your request in writing. Your request must specify the alternative means or location and provide satisfactory explanation of how payment for treatment will be handled under the alternative means or location you request.

Breach Notification

In the event your unsecured protected health information is breached, we will notify you as required by law. In some situations, you may be notified by our business associates.

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.

Notice of Privacy Practices

You have the right to a paper copy of this notice at any time.

If you want more information about our privacy practices or have questions or concerns, please contact us at:

Advanced Restorative Dentistry
Michael L. Nishime, D.D.S.
1401 S. Beretania St.
Suite 470
Honolulu, HI 96814
Phone: (808) 732-0291
Email: mnishimedds@gmail.com

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 send a written complaint to our office or to the U.S. Department of Health and Human Services, Office of Civil Rights. We will not retaliate against you for filing a complaint. Advanced Restorative Dentistry complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.