Privacy Policy

Disclosure: 

We may disclose and/or share your healthcare information with other health care professionals who provide treatment and/or service to you.  These professionals will have a privacy and confidentiality policy like this one.  Health information about you may also be disclosed to your family, friends and/or other persons you choose to involve in your care, only if you agree that we may do so.

Payment: 

We may use and disclose your health information to seek payment for services we provide to you.  This disclosure involves our business office staff and may include insurance organizations or other businesses that may become involved in the process of mailing statements and/or collecting unpaid balances.

Emergencies:

We may use or disclose your health information to notify, or assist in the notification of a family member or anyone responsible for your care, in case of any emergency involving your care, your location, your general condition or death.  If at all possible we will provide you with an opportunity to object to this use or disclosure.  Under emergency conditions or if you are incapacitated we will use our professional judgment to disclose only that information directly relevant to your care.  We will also use our professional judgment to make reasonable inferences of your best interest by allowing someone to pick up filled prescriptions, x-rays or other similar forms of health information and/or supplies unless you have advised us otherwise.

Healthcare Operations: 

We will use and disclose your health information to keep our practice operable.  Examples of personnel who may have access to this information include, but are not limited to, our medical records staff, outside health or management reviewers and individuals performing similar activities.

Required by Law: 

We may use or disclose your health information when we are required to do so by law.  (Court or administrative orders, subpoena, discovery request or other lawful process.)  We will use and disclose your information when requested by national security, intelligence and other State and Federal officials and/or if you are an inmate or otherwise under the custody of law enforcement.

Abuse or Neglect: 

We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes.   This information will be disclosed only to the extent necessary to prevent a serious threat to your health or safety or that of others.

Public Health Responsibilities: 

We will disclose your health care information to report problems with products, reactions to medications, product recalls, disease/infection exposure and to prevent and control disease, injury and/or disability.

Marketing Health-Related Services: 

We will not use your health information for marketing purposes unless we have your written authorization to do so.

National Security:

The health information of Armed Forces personnel may be disclosed to military authorities under certain circumstances.  If the information is required for lawful intelligence, counterintelligence or other national security activities, we may disclose it to authorized federal officials.

Appointment Reminders: 

We may use or disclose your health information to provide you with appointment reminders, including, but not limited to, voicemail messages, postcards or letters.

Your Privacy Rights As Our Patient

Access: 

Upon written request, you have the right to inspect and get copies of your health information (and that of an individual for whom you are a legal guardian.)  There will be some limited exceptions.  If you wish to examine your health information, you will need to complete and submit an appropriate request form.  Contact our Privacy Officer for a copy of the Request Form.    You may also request access by sending us a letter to the address at the end of this Notice.  Once approved, an appointment can be made to review your records.  Copies, if requested, will be $ .35 for each page and the staff time charged will be $ 15.00 per hour including the time required to locate and copy your health information.  If you want the copies mailed to you, postage will also be charged.  If you prefer a summary or an explanation of your health information, we will provide it for a fee.  Please contact our Privacy Officer for a fee and/or for an explanation of our fee structure.

Amendment: 

You have the right to amend your healthcare information, if you feel it is inaccurate or incomplete.  Your request must be in writing and must include an explanation of why the information should be amended.  Under certain circumstances, your request may be denied.

Non-routine Disclosures: 

You have the right to receive a list of non-routine disclosures we have made of your health care information.  (When we make a routine disclosure of your information to a professional for treatment and/or payment purposes, we do not keep a record of routine disclosures: therefore these are not available.)  You have the right to a list of instances in which we, or our business associates, disclosed information for reasons other than treatment, payment or healthcare operations.  You can request non-routine disclosures going back 6 years starting on April 14, 2003.  Information prior to that date would not have to be released. (Example: If you request information on May 15, 2004, the disclosure period would start on April 14, 2003 up to May 15, 2004.  Disclosures prior to April 14, 2003 do not have to be made available.)

Restriction Disclosure to a Health Plan:

You have the right to request that we place additional restrictions on our use or disclosure of your health information.   We do not have to agree to these additional restrictions except in emergencies or if the following two criteria are met: 1) if the patient asks the dental practice not to disclose information about a health care item to a health plan for payment or operations purposes, and 2) the dental practice has been paid in full for the item or the service by the patient or by another on behalf of the patient.  Please contact our Privacy Officer if you want to further restrict access to your health care information.  This request must be submitted in writing.

Breach notification:

The practice is required by law to notify affected individuals following a breach of unsecured patient information.

Authorizations/Marketing and sale of PHI:

The practice cannot sell patient information without the patient’s express written authorization, and that authorization is also required for certain marketing communications. Other uses and disclosures not described in the Notice of Privacy Practices will be made only with the patient’s written authorization. The patient may revoke an authorization at any time, as long as the patient does so in writing, but:1) if the dental practice has already relied on the authorization to use or disclose patient information the revocation cannot apply to those uses or discloses, and 2) if the authorization was for purposes of obtaining insurance coverage, other law gives the insurance company certain rights.

Questions and Complaints

You have the right to file a complaint with us if you feel we have not complied with our Privacy Policies.  Your complaint should be directed to our Privacy Officer.  If you feel we may have violated your privacy rights, or if you disagree with a decision we made regarding your access to your health information, you can complain to us. In writing.  Request a Complaint Form from our Privacy Officer.  We support your right to the privacy of your information and will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

How to Contact Us

Practice Name: Jason D. Roe, DDS, PLLC

Privacy Officer: Jason Roe DDS

Telephone: (972) 931-1777

Fax: (972) 931-8259

Email: [email protected]

Address: 5136 Village Creek Drive #501 Plano, TX 75093