Roxbury Family Dentistry, PC 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.
Roxbury Family Dentistry, PC is committed to protecting your health information. This
notice explains how we will use, share and protect your health information. It also
explains your rights to privacy of your health information as required by law. If our
confidentiality practices change, a new notice will be mailed to you within sixty (60)
days of the change.
Uses, Sharing and Protection of Health Information
The law only allows our staff to use your health information when doing their jobs or
to share your information when it is necessary to run the program. When health
information is shared with other agencies or organizations, our office requires them to
keep your health information confidential. Your health information will be shared to
approve or deny treatment, and to determine if you are getting the right dental
treatment. For example, doctors and assistants employed by our practice may review
the treatment plan created for you by your health care provider to make sure the care
you receive is covered by your dental insurance.
The Practice Will Use and Share Your Health Information Without Authorization
Make payments to your health care providers for dental services provided to you.
Coordinate payment for your care between the practice, other health plans, and
other insurance companies that may be responsible for the cost of your care.
Coordinate your care between the practice, other health plans, and health care
providers to improve the quality of your health care.
Evaluate the performance of your health care provider. For example, the practice
contracts with consultants to review office and other facilities’ medical records to
check on the quality of care you received.
Release information to its attorneys, accountants, and consultants so that the
practice is run efficiently and to detect and prosecute insurance fraud and abuse.
Send you helpful information such as insurance benefit updates, free orthodontic
exams and consumer protection information.
Share information with government agencies or organizations that provide benefits
or services when the information is necessary in order for you to receive those
benefits or services.
The Program May Disclose Your Health Information Without Authorization:
To public health agencies for activities such as disease control and prevention,
problems with medical products or medications.
If you are the victim of abuse, neglect or domestic violence.
To health oversight agencies responsible for the Medicaid Program such as the U.S.
Department of Health and Human Services and its Office of Civil Rights.
In court cases or judicial and administrative hearings when required by law to run
To coroners, medical examiners, and funeral directors so they can carry out their
jobs as required by law.
To organizations involved with organ donation and transplantation, communicable
disease registries and cancer registries.
To entities authorized to conduct a research project.
To prevent a serious threat to a person’s or the public’s health and safety.
To the military if you are or have been a member of the armed services.
To a correctional facility or law enforcement officials to maintain the health, safety,
and security of the corrections systems, if you are held in custody.
To workers’ compensation programs that provide benefits for work-related injuries
or illness without regard to fault.
To law enforcement or national security and intelligence agencies, and to protect
the President and others as required by law.
With your consent, the practice 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 or treatment. It also includes billing documents for
Example 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
guidelines 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 record we maintain and billing records are the physical property of the
practice. 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 comply with any request granted;
• Obtain a paper copy of this Notice of Privacy Practices for Protected Health
Information (“Notice”) by making a request at our office;
• 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
• Appeal a denial of access to your protected health information except in certain
• Request that your health care record be amended to correct incomplete or
incorrect information by delivering a written request to our office;
• File a statement of disagreement if your amendment is denied, and require that the
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
• 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 these rights, please contact, Joan Bozich in person or in
writing, during normal hours. She will help you with assistance on the steps to exercise
your rights. You have the right to review this Notice before signing the consent authorizing use
and disclosure of your protected health information for treatment, payment, and
health care operations purposes.
The practice 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 requested restriction or request; and
• Accommodate your reasonable requests regarding methods to communicate
health information with 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 calling and
requesting a copy of our “Notice” or by visiting our office and picking up 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 Joan Bozich.
You will not be retaliated against for filing a complaint.
Additionally, if you believe your privacy rights have been violated, you may file a
written complaint at our office by delivering the written complaint to Joan Bozich by
address 168 Route 10 West, Succasunna, NJ 07876, or email
You may also file a complaint by mailing it to the Secretary of Health and Human
Services 200 Independence Ave, SW, HHH Building Room 509H, Washington, DC 20201
We cannot, and will not, require you to waive the right to file a complaint with the
Secretary of Health and Human Services (HHS) as a condition of receiving treatment
from the practice. We cannot, and will not, retaliate against you for filing a complaint with the Secretary.
Other Disclosures and Uses
Unless you object, we may use or disclose your protected health information to notify,
or assist in notifying, a family member, personal representative, or other person
responsible for your care, about your location, and about your general condition, or your
Communication with Family
Using our best judgment, we may disclose to a family member, other relative, close
personal friend, or any other person you identify, health information relevant to that
person’s involvement in your care or in payment for such care if you do not object or
in an emergency.
Food and Drug Administration (FDA)
We may disclose to the FDA your protected health information relating to adverse
events with respect to products and product defects, or post-marketing surveillance
information to enable product recalls, repairs, or replacements.
If you are seeking compensation through Workers Compensation, we may disclose your
protected health information to the extent necessary to comply with laws relating to
As required by law, we may disclose your protected health information to public
health or legal authorities charged with preventing or controlling disease, injury,
Abuse & Neglect
We may disclose your protected health information to public authorities as allowed
by law to report abuse or neglect.
If you are an inmate of a correctional institution, we may disclose to the institution, or
its agents, your protected health information necessary for your health and the health
and safety of other individuals.
We may disclose your protected health information for law enforcement purposes
as required by law, such as when required by a court order, or in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement.
Federal law allows us to release your protected health information to appropriate
health oversight agencies or for health oversight activities.
We may disclose your protected health information in the course of any judicial or
administrative proceeding as allowed or required by law, with your consent, or as
directed by a proper court order.
Other uses and disclosures besides those identified in this Notice will be made only
as otherwise authorized by law or with your written authorization and you may
revoke the authorization as previously provided.
For More Information
If you have any questions about this notice or need more information, please contact the
office Privacy Officer. Roxbury Family Dentistry, PC, may change its Notice of Privacy
Practices. Any changes will apply to information we already have, as well as any
information we may get in the future. A copy of any new notice will be posted at our
office as well as on our web site. You may ask for a copy of the current notice at any
time, or get it on-line at firstname.lastname@example.org . Additionally, this platform
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