Privacy Policy

Kool Smiles, P.C. (d/b/a Kool Smiles), Fox Plaza, P.C. (d/b/a Buena Vista Dental), and their dental clinic and practice services affiliates
JOINT NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW DENTAL INFORMATION ABOUT YOU AND/OR YOUR CHILD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.

Kool Smiles, P.C. Fox Plaza, P.C., and their dental clinic and practice services affiliates will be referred to in this Notice of Privacy Practices (“Notice”) as “Kool Smiles”. Our practice is dedicated to maintaining the privacy of you and/or your child’s dental information (called “protected health information” or “PHI”). In conducting business, Kool Smiles will create records, both paper and electronic, regarding you and/or your child’s treatment and the services provided. This Notice is given to you by Kool Smiles to describe the ways in which we may use and disclose your and/or your child’s “PHI” and to notify you of your and/or your child’s rights with respect to PHI in the possession of Kool Smiles. Kool Smiles protects the privacy of PHI, which is also protected from disclosure by state and federal law. In certain circumstances, pursuant to this Notice, patient authorization, parental or legal guardian consent or applicable laws and regulations, PHI can be used by Kool Smiles or disclosed to other parties. Below are categories describing these uses and disclosures, along with some examples to help you better understand each category. The examples given are for descriptive purposes and are not meant to be all-inclusive.

Uses and Disclosures for Treatment, Payment and Dental Care Operations: Kool Smiles may use or disclose your or your child’s PHI for the purposes of treatment, payment and dental care operat ions , described in more detall below, without obtaining written authorization from you.

For Treatment: Kool Smiles may use and disclose PHI in the course of providing, coordinating, or managing your and/or your child’s dental treatment, including the disclosure of PHI for treatment activities of another dental or health care provider. These types of uses and disclosures may take place between dentists, physicians, dental assistants, dental hygienists, nurses, technicians, students, and other health care professionals who provide your and/or your child’s dental services or are otherwise involved in your and/or your child’s care. For example: if your child is being treated by a primary dentist, that dentist may need to use/disclose PHI to a specialist dentist whom he or she consults regarding your child’s condition, or to a dental hygienist or assistant who is assisting in your child’s care. In addition, elements of your and/or your child’s PHI may be used on patient sign-in sheets or to contact and remind you of an appointment.

For Payment: Kool Smiles may use and disclose PHI in order to bill and collect payment for the dental services provided to you and/or your child. For example, Kool Smiles may need to give PHI to you and/or your child’s health plan in order to be reimbursed for the services provided to you and/or your child. Kool Smiles may also disclose PHI to their business associates, such as billing companies, claims processing companies, and others that assist in processing health claims. Kool Smiles may also disclose PHI to other health care providers for the payment activities of such providers.

For Dental Care Operations: Kool Smiles may use and disclose PHI as part of their operations, such as quality assessment and improvement to evaluate the treatment and services you and/or your child receives and the performance of our staff. Other activities include provider training, underwriting activities, compliance and risk management activities, planning and development, and management and administration. Kool Smiles may disclose PHI to dentists, dental hygienists, dental assistants , doctors, nurses, technicians, attorneys, consultants, accountants, and others for review and learning purposes. These disclosures help make sure that Kool Smiles is complying with all applicable laws, and is continuing to provide dentistry to patients at a high level of quality. Kool Smiles may also disclose PHI to other dental/health care providers and health plans for certain of their operations, including their quality assessment and improvement activities, credentialing and peer review activities, and dental/health care fraud and abuse detection or compliance, provided that those other providers and plans have, or have had in the past, a relationship with the patient who is the subject of the information.

Other Uses and Disclosures for Which Authorization is Not Required: In addition to using or disclosing PHI for treatment, payment and dental care operations, Kool Smiles may use and disclose PHI without your written authorization under the following circumstances:

As Required by Law and Law Enforcement: Kool Smiles may use or disclose PHI when required by law. Kool Smiles also may disclose PHI when ordered to in a judicial or administrative proceeding, in response to subpoenas or discovery requests, to identify or locate a suspect, fugitive, material witness, or missing person, when dealing with gunshot and other wounds, about criminal conduct, to report a crime, its location or victims, or the identity, description or location of a person who committed a crime, or for other law enforcement purposes.

For Public Health Activities and Public Health Risks: Kool Smiles may disclose PHI to government officials in charge of collecting information about preventing and controlling disease, reports of child abuse or neglect and of other victims of abuse, neglect, or domestic violence, reactions to medications or product defects or problems, or to notify a person who may have been exposed to a communicable disease or may be at risk of contracting or spreading a disease or condition.

To Avoid a Serious Threat to Health or Safety: Kool Smiles may use and disclose PHI to law enforcement personnel or other appropriate persons, to prevent or lessen a serious threat to the health or safety of a person or the public.

Appointment Reminders & Limited Marketing Activities: Kool Smiles may use and disclose PHI to remind you and/or your child of an appointment, or to inform you and/or your child of treatment alternatives or other health-related benefits and services that may be of interest to you, such as oral disease management programs.

Disclosures to You or for HIPAA Compliance Investigations: Kool Smiles may disclose your PHI to you or to your personal representative, and are required to do so in certain circumstances described below in connection with your rights of access to your PHI and to an accounting of certain disclosures of your PHI. Kool Smiles must disclose you and/or your child’s PHI to the -Secretary of the U.S. Department of Health and Human Services (the “Secretary”) when requested by the Secretary in order to investigate compliance with Privacy regulations issued under the federal Health Insurance Portability and Accountability Act of 1996 (“HIPAA”).

Uses and Disclosures to Which You May Object: You may object to the following uses and disclosures of PHI that Kool Smiles may make:

Disclosures to Individuals Involved in You and/or Your child’s Dental Care or Payment for Your Dental Care: Unless you object, Kool Smiles may disclose your PHI to a family member, other relative, friend, or other person you identify as involved in your and/or your child’s dental care or payment for your dental care. We may also notify those people about your and/or your child’s condition.

Other Uses and Disclosures of PHI For Which Authorization is Required: Other types of uses and disclosures of your and/or your child’s PHI not described above will be made only with your written authorization, which you have the limited right to revoke in writing.

Regulatory Requirements: Kool Smiles is required by law to maintain the privacy of your and/or your child’s PHI, to provide individuals with notice of their legal duties and privacy practices with respect to PHI, and to abide by the terms described in this Notice. Kool Smiles reserves the right to change the terms of this Notice and of its privacy policies, and to make the new terms applicable to all PHI it maintains. Before Kool Smiles makes an important change to their joint privacy policies, they will promptly revise this Notice and post a new Notice in all locations.

Activities of an Affiliated Covered Entity in Which We Participate. Separate legal entities may elect under HIPAA to designate themselves as an Affiliated Covered Entity (ACE) and are treated, for HIPAA purposes only, as comprising one Covered Entity. This means we may use one joint Notice of Privacy Practices and may disclose information about you to Covered Entities within the ACE, including for treatment, payment and other purposes.

You have the following rights regarding your PHI: You may request that Kool Smiles restrict the use and disclosure of your PHI. Kool Smiles is not required to agree to any restrictions you request; but if the entity does so it will be bound by the restrictions to which it agrees except in emergency situations.

You have the right to request that communications of PHI to you from Kool Smiles be made by particular means or at particular locations. For instance, you might request that communications be made at your work address rather than your home address. Your requests must be in writing and sent to the Privacy Officer. Kool Smiles will accommodate reasonable requests without requiring you to provide a reason.

Generally, you have the right to inspect and copy your PHI in the possession of Kool Smiles, if you make a request in writing to the Privacy Officer.

Within thirty (30) days of receiving your request (unless extended by an additional thirty (30) days), Kool Smiles will inform you of the extent to which your request has or has not been granted. In some cases, Kool Smiles may provide you a summary of the PHI you request if you agree in advance to such a summary and any associated fees. If you re-quest copies of your PHI or agree to a summary of your PHI Kool Smiles may impose a reasonable fee to cover copying, postage, and related costs. If Kool Smiles denies access to your PHI, it will explain the basis for denial and your opportunity to have your denial reviewed by a licensed health care professional (not involved in the initial denial decision) designated as a reviewing official. If Kool Smiles does not maintain the PHI you request, and if it knows where that PHI is located, it will tell you how to redirect your request.

If you believe that you and/or your child’s PHI maintained by Kool Smiles contains an error or needs to be updated, you have the right to request that the entity correct or supplement your child’s PHI. Your request must be made in writing to the Privacy Officer, and must explain why you are requesting a n amendment to your PHI. Within sixty (60) days of receiving your request (unless extended by an additional thirty (30) days), Kool Smiles will inform you of the extent to which your request has or has not been granted. Kool Smiles generally can deny your request if your request relates to PHI: (i) not created by the entity; (ii) that is not part of the records the entity maintains; (iii) that is not subject to being inspected by you; or (iv) that is accurate and complete. If your request is denied, Kool Smiles will give you a written denial that explains the reason for the denial and your rights to: (i) file a statement disagreeing with the denial; (ii) if you do not file a statement of disagreement, submit a request that any future disclosures of the relevant PHI be made with a copy of your request and the entity’s denial attached; and (iii) complain about the denial.

You generally have the right to request and receive a list of disclosures of you and/or your child’s PHI Kool Smiles has made during the six (6) years prior to your request (but not before April 1, 2003). The list will not include disclosures (i) for which you have provided a written authorization; (ii) for treatment, payment, and dental care operations; (iii) made to you; (iv) to persons involved in your dental care; (v) for national security or intelligence purposes; (vi) to correctional institutions or law enforcement officials; or (vii) of a limited data set. You should submit any such request to the Privacy Officer. Within sixty (60) days of receiving your request (unless extended by an additional thirty (30) days), Kool Smiles will respond to you regarding the status of your request. The entity will provide the list to you at no charge, but if you make more than one request in a year you will be charged a fee of $25.00 for each additional request.

You have the right to receive a paper copy of this notice upon request. To obtain a paper copy of this notice, please contact the Privacy Officer.

You may complain to Kool Smiles if you believe privacy rights, with respect to your and/or your child’s PHI have been violated by contacting the Privacy Officer and submitting a written complaint. Kool Smiles will not penalize you or retaliate against you for filing a complaint regarding their privacy practices. You also have the right to file a complaint with the Secretary of the Department of Health and Human Services.

If you have any questions about this notice, please contact the Kool Smiles Privacy Officer at (770) 916- 9000. You may also contact the Privacy Officer by mail at:

Kool Smiles Patient Support c/o Benevis Practice Services
1090 Northchase Parkway SE,
Suite 150 & 290
Marietta, GA 30067.

Effective March 31, 2003