Notice of Privacy Practice
Dr Itza Rosado, D.D.S.
We respect our legal obligation to keep health information that identifies you private. We are
obligated by law to give you notice of our privacy practices. This notice describes how we protect your
health information and what rights you have regarding it.
TREATMENT, PAYMENT AND HEALTH CARE OPERATIONS
Treatment – setting up an appointment for you, examining your teeth, prescribing
medications and faxing them to be filled, referring you to another doctor or clinic for other
health care services, or getting copies of your health information from another professional
that may have seen you before us.
Payment – asking you about your health or dental care plans, or other sources of payment,
preparing and sending of bills or claims, and collecting unpaid amounts (either ourselves or
through a collection agency or attorney).
Health Care Operations – financial or billing audits, internal quality assurance, personnel
decisions, participation in managed care plans, defenses of legal matters, business planning,
and outside storage of our records.
ADDITIONAL USES AND DISCLOSURES
When state or federal law mandates that certain health information be reported
For public health purposes, such as contagious disease reporting
Disclosure to government about victims of suspected abuse, neglect or domestic violence
Uses and disclosures for health oversight activities, such as for the licensing of doctors, for
audits by Medicare or Medicaid, or for investigation of possible violations of health care laws
Disclosures for judicial and administrative proceedings, such as in response to subpoenas or
orders of courts or administrative agencies
Disclosures for law enforcement purposes, such as to provide information about someone
suspected to be a victim of a crime, to provide information about a crime at our office.
Disclosure to a medical examiner to identify a dead person or to determine the cause of death
Disclosure of de-identified information
Disclosure of relating to worker’s compensation programs
Disclosure of a “limited data set” for research, public health or health care operations’
Incidental disclosures that are an unavoidable by-product or permitted uses or disclosures
Unless you object we will share relevant information about your care with your family or friends who
are helping you with your dental care.
APPOINTMENT REMINDERS
We may call or write to remind you of scheduled appointments, or that is time to make a routine
appointment. We may also call or write to notify you of other treatments or services available to our
office that might help you. Unless you tell us otherwise, we will mail you an appointment reminder on
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
a postcard, and/or leave you a reminder message on you answering machine or with someone who
answer your phone if you are not home.
YOUR RIGHTS REGARDING YOUR HELATH INFORAMTION
Request that we place additional restrictions on our disclosure of your medical information.
We are not required to agree to these additional restrictions, but if we do, we will abide by
our agreement (except in the case of an emergency)
Request that we communicate with you about your medical information by different means or
to different locations. This request must be made in writing.
Look at or get copies of your medical information. You may request that we provide copies in
a format other than photocopies. We will use the format you request unless it is not practical
for us to do so. You must make your request in writing. If you request copies, we will charge
you $o.25 for each page and postage if you want the copies mailed to you.
Request that we change your medical information. We may deny your request if we did not
create the information you wanted changed or for certain reasons. If we deny your request,
we will provide you a written explanation. You may respond with a statement of
disagreement that will be added to the information you want changed. If we accept the
request, we will make reasonable efforts to tell other including the people you name and to
include the changes in any further sharing of information.
Receive a list of all the times we shared your medical information for purposes other than
treatment, payment, and health care operations and other specified exceptions.
OUR NOTICE OF PRIVACY PRACTICES
By law we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We
reserve the right to change at any time as allowed by law. If we change this Notice, the new privacy
practices will apply to your health information that we already have as well as to such information
that we may generate in the future. If we change our Notice of Privacy Practices we will post the new
notice in our office.
COMPLAINTS
If you think we have not properly respected the privacy of your health information, you are free to
complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will
not retaliate against you if you make a complaint. If you want to complain on us, send a written
complaint to the office contact person.