Purpose: The Dental Faculty Private Practice follows the privacy practices described in this Notice. For purposes of this Notice, the Dental Faculty Private Practice is defined as all professional staff, and employees (hereinafter DFPP). DFPP maintains your health information in records that will be maintained in a confidential manner, as required by law. However, DFPP must use and disclose your health information to the extent necessary to provide you with quality health care. To do this, DFPP must share your health information as necessary for treatment, payment and health care operations. This Notice takes effect April 14, 2003 and will remain in effect until we replace it.

What are Treatment, Payment, and Health Care Operations? Treatment includes sharing information among health care providers involved in your care. For example, your physician or dentist may share information about your condition with the pharmacist to discuss appropriate medications, or with radiologists or other consultants in order to make a diagnosis. DFPP may use your health information as required by your insurer or HMO to obtain payment for your treatment and/or hospital stay. We also may use and disclose your health information to improve the quality of care (health care operations), e.g. , for review and training purposes.

• Family members or close friends involved in your care or payment for your treatment.

• Business Associates: We contract with outside organizations, called business associates, to perform some of our operational tasks on our behalf. Examples would include billing agencies and a copy service we use when making copies of your health record. When these services are performed, we disclose the necessary health information to these companies so that they can perform the tasks we have asked them to do, and bill you or your third-party payer for services rendered. To protect your health information, however, we require the business associate to appropriately safeguard your information.

• Disaster relief agency if you are involved in a disaster relief effort.

• Appointment reminders (such as voicemail messages, postcards or letters).

• To inform you of treatment alternatives or benefits or services related to your health. (You will have an opportunity to refuse to receive this information.)

• As required by law. We will disclose your health information when we are required to do so by federal, state or local law.

• Public health activities, including disease prevention, injury or disability; reporting births and deaths; reporting child abuse or neglect; reporting reactions to medications or product problems, notification of recalls; infectious disease control; notifying government authorities of suspected abuse, neglect or domestic violence.

• Health oversight activities, e.g. , audits, inspections, investigations, and licensure.

• Lawsuits and disputes. If you are involved in a lawsuit or a dispute, we may disclose information about you in response to a court or administrative order. We may also disclose information about you in response to a subpoena, discovery request or other lawful process by someone else involved in the dispute.

• Law enforcement (e.g. , in response to a court order or other legal process; to identify or locate an individual being sought by authorities; about the victim of a crime under restricted circumstances; about a death that may be the result of criminal conduct; about criminal conduct that occurred on DFPP premises; and in emergency circumstances relating to reporting information about a crime.)

• Coroners, medical examiners, and funeral directors.

• Organ and tissue donation.

• Certain research projects. Under certain circumstances, we may use and disclose health information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who received another, for the same condition. All research projects, however, are subject to a special approval process. This process evaluates a proposed research project and its use of health information, trying to balance the research needs with patients' need for privacy of their health information. Before we use or disclose health information for research, the project will have been approved through this research approval process; but we may disclose health information about you to people preparing to conduct a research project. For example, we may help potential researchers look for patients with specific health needs, so long as the health information they review does not leave our facility. We will almost always ask for your specific permission if the researcher will have access to your name, address, or other information that reveals who you are, or will be involved in your care.

• To prevent a serious threat to health or safety.

• To military command authorities if you are a member of the armed forces or a member of a foreign military authority.

• National security and intelligence activities.

• Protection of the President or other authorized persons for foreign heads of state, or to conduct special investigations.

• Inmates. (Health information about inmates of correctional institutions may be released to the institution.)

• Workers' Compensation. (Your health information regarding benefits for work-related illnesses may be released as appropriate.)

• To carry out health care treatment, payment, and operations functions through business associates, e.g. , to install a new computer system.

Your Authorization Is Required for Other Disclosures. Except as described above in this Notice, we will not use or disclose your health information unless you authorize (permit) DFPP in writing to disclose your information. You may revoke your permission, which will be effective only after the date of your written revocation.

You Have Rights Regarding Your Health Information. You have the following rights regarding your health information, provided that you make a written request to invoke the right on the form provided by DFPP:

• Right to request restriction. You may request limitations on your health information we use or disclose for health care treatment, payment, or operations (e.g., you may ask us not to disclose that you have had a particular surgery), but we are not required to agree to your request. If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment. You may request a restriction on the form provided by DFPP. The request should be filed by using the contact information at the end of this Notice.

• Right to confidential communications. You may request communications in a certain way or at a certain location, but you must specify how or where you wish to be contacted. You may request confidential handling of information on the form provided by DFPP. The request should be filed using the contact information at the end of this Notice.

• Right to inspect and copy. You have the right to inspect and copy your health information regarding decisions about your care including mental health notes, however, mental health records may be withheld if the health care provider determines, in their best judgment, that the information requested is detrimental to the physical and mental health of the patient, or likely to cause the patient to harm himself or another person. Upon written request and reasonable notice, you may request access and/or copies by using the contact information at the end of this Notice. We may charge a fee for copying, mailing and supplies. Under limited circumstances, your request may be denied; you may request review of the denial by another licensed health care professional chosen by DFPP. DFPP will comply with the outcome of the review.

• Right to request amendment. If you believe that the health information we have about you is incorrect or incomplete, you may request an amendment on the form provided by DFPP, which requires certain specific information. The request should be filed using the contact information at the end of this Notice. DFPP is not required to accept the amendment.

• Right to accounting of disclosures. You may request a list of the disclosures of your health information that have been made to persons or entities other than for health care treatment, payment, or operations in the past six (6) years, but not prior to April 14, 2003. After the first request in a 12-month period, there may be a charge. You may request an accounting of disclosures on the form provided by DFPP. The request should be filed using the contact information at the end of this Notice.

• Right to a copy of this Notice. You may request a paper copy of this Notice at any time, even if you have been provided with an electronic copy. You may obtain an electronic copy of this Notice at our web site.

Requirements Regarding This Notice. DFPP is required by law to provide you with this Notice. We will be governed by this Notice for as long as it is in effect. DFPP may change this Notice and these changes will be effective for health information we have about you as well as any information we receive in the future. Each time you register at DFPP for health care services as an inpatient or outpatient, you may receive a copy of the Notice in effect at that time.

Complaints. If you believe your privacy rights have been violated, you may file a complaint with DFPP or with the Secretary of the United States Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized or retaliated against in any way for making a complaint to DFPP or the Department of Health and Human Services .

Please call Ms. Jill Allen, Privacy Officer at: (317) 278-6946,
FAX: (317) 274-6594, e-mail: ds-fcprc@iupui.edu or
Mail: Dental Faculty Private Practice, 1121 W. Michigan Street Room 286B, Indianapolis, IN 46202

• If you have a complaint;

• If you have any questions about this Notice;

• If you wish to request restrictions on uses and disclosures for health care treatment, payment, or operations; or

• If you wish to obtain a form to exercise your individual rights described in paragraph 5.

OTHER USES OF HEALTH INFORMATION
Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission and that we are required to retain our records of the care that we provided to you.

Acknowledgement of Receipt of this Notice
We request that you sign a separate form or notice acknowledging that you have received a copy of this Notice. If you do not, a staff member will record this fact. This acknowledgement will be filed with your records.