PRIVACY POLICY

Orthodontic Specialists of Tucson, PC

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

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 you this Notice about our privacy practices, 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 August 1, 2017, 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 that
we maintain, including 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 information about our privacy
practices, or for additional copies of this Notice, please contact us using the information listed at
the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare
operations. For example:
Treatment: We may use or disclose your health information to a physician or other healthcare
provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we
provide to you.
Healthcare Operations: We may use and disclose your health information in connection with
our healthcare operations. Healthcare operations include quality assessment and improvement
activities, reviewing the competence or qualifications of healthcare professionals, evaluating
practitioner and provider performance, conducting training programs, accreditation, certification,
licensing or credentialing activities.
Your Authorization: In addition to our use of your health information for treatment, payment or
healthcare operations, you may give us written authorization to use your health information or to
disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in
writing at any time. Your revocation will not affect any use or disclosures permitted by your
authorization while it was in effect. Unless you give us a written authorization, we cannot use or
disclose your health information for any reason except those described in this Notice.
To Your Family and Friends: We must disclose your health information to you, as described
in the Patient Rights section of this Notice. We may disclose your health information to a family
member, friend or other person to the extent necessary to help with your healthcare or with
payment for your healthcare, but only if you agree that we may do so.
Persons Involved In Care: We may use or disclose health information to notify, or assist in the
notification of (including identifying or locating) a family member, your personal representative
or another person responsible for your care, of your location, your general condition, or death. If
you are present, then prior to use or disclosure of your health information, we will provide you
with an opportunity to object to such uses or disclosures. In the event of your incapacity or
emergency circumstances, we will disclose health information based on a determination using
our professional judgment disclosing only health information that is directly relevant to the
person’s involvement in your healthcare. We will also use our professional judgment and our
experience with common practice to make reasonable inferences of your best interest in allowing
a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health
information.
Marketing Health-Related Services: We will not use your health information for marketing
communications without your written authorization.
Required by Law: We may use or disclose your health information when we are required to do
so by law.
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. We may disclose your health information to the extent necessary
to avert a serious threat to your health or safety or the health or safety of others.
National Security: We may disclose to military authorities the health information of Armed
Forces personnel under certain circumstances. We may disclose to authorized federal officials
health information required for lawful intelligence, counterintelligence, and other national
security activities. We may disclose to correctional institution or law enforcement official having
lawful custody of protected health information of inmate or patient under certain circumstances.
Appointment Reminders: We may use or disclose your health information to provide you with
appointment reminders (such as voicemail messages, postcards, or letters).

PATIENT RIGHTS

Access: You have the right to look at or get copies of your health information, with limited
exceptions. You may request that we provide copies in a format other than photocopies. We will
use the format you request unless we cannot practicably do so. (You must make a request in
writing to obtain access to your health information. You may obtain a form to request access by
using the contact information listed at the end of 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 at the end of this Notice. If you request copies, we will charge
you $0.25 for each page, $15.00 per hour for staff time to locate and copy your health
information, and postage if you want the copies mailed to you. If you request an alternative
format, we will charge a cost-based fee for providing your health information in that format. If
you prefer, we will prepare a summary or an explanation of your health information for a fee.
Contact us using the information listed at the end of 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.
Restriction: 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 your 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 certain circumstances.
Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you
are entitled to receive this Notice in written form.

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 in response to a request you made
to amend or restrict the use or disclosure of your health information or to have us communicate
with you by alternative means or at alternative locations, you may complain to us using the

contact information listed at the end of this Notice. You also may submit a written complaint to
the U.S. Department of Health and Human Services. We will provide you with the address to file
your complaint with the U.S. Department of Health and Human Services upon request.
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 us or with the U.S. Department of Health and Human
Services.
Contact Officer: Mittida Raksanaves Telephone: Tucson Office Phone Number 520-742- 1232

Fax: 520-742- 0925

Address: 1320 W. Ina Rd. Tucson, AZ 85704

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Dr. Daniel Pearcy & Dr. Mittida Raksanaves your Tucson Orthodontists provide Orthodontic Treatment for Teens, Children & Adults including Braces, Lingual Braces, Invisible Braces, Clear Aligners, Gold Braces, Herbst, Invisalign, Space Maintainers, Headgear, & Retainers

 

Address

1320 West Ina Road
Tucson AZ 85704

Phone

520-742-1232

Email

info@supersmilz.com

Accessibility: Click Here
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