THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.  THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

 

1.  OUR LEGAL DUTY

 

We are required by applicable federal and state law to maintain the privacy of your health information.  We are also required to give this Notice about our privacy practices, and our legal duties and your rights concerning your health information.  We must follow the privacy practices that are described in this Notice while it is in effect.  This Notice takes effect April 14, 2003 and will remain in effect until we replace it.

 

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law.  We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information we created or received before we made the changes.  Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

 

You may request a copy of our Notice at any time.  For more additional information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed in this Notice.

 

2.  PATIENT RIGHTS

 

ACCESS:  You have the right to look at or get copies of your health information, with limited exemptions.  You may request that we provide copies in a format other than photocopies.  We will use the format you request unless we cannot practically do so.  You must make a request in writing to obtain access to your health information listed in this Notice.  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 to the address in this Notice.  If you request copies, we will charge you $1.50 for each page, $32.50 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you.  If you prefer, we will prepare a summary or an explanation of your health information for a fee.  Contact us using the information listed in this Notice for a full explanation of our fee structure.

 

DISCLOSURE ACCOUNTING:  You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003.  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.

 

RESTRICTIONS:  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 an emergency.

 

ALTERNATIVE COMMUNICATION:  You have the right to request that we communicate with you about hour health information by alternative means, or to alternative locations.  You must make your request in writing.  Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

 

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 special circumstances.

 

3.  QUESTIONS AND COMPLAINTS

 

If you want more information about our privacy practices or have questions or concerns, please contact us.  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 to have us communicate with you by alternative means or locations, you may complain to us using the contact information listed at the end of this Notice.  You may also submit a written complaint to the Office for Civil Rights.

 

We support your right to the privacy of your health information.  We will not retaliate in any way if you choose to file a complaint with the Privacy Officer or with the Office for Civil Rights.

 

Privacy Officer:  Joanne M. Butler, D.D.S.

Telephone:  (516) 365-8005

Fax:  (516) 627-7683

Address:  166 Park Avenue, Manhasset, New York  11030

 

Office for Civil Rights U.S. Department of Health and Human Services

Room 509F, HHH Building

200 Independence Avenue, S.W.

Washington, D.C.  20201

JOANNE M. BUTLER D.D.S.

NOTICE OF PRIVACY PRACTICES