Patient Privacy Policy

Lakeside Oral & Facial Surgery Institute

NOTICE OF PRIVACY PRACTICES

Effective Date: April 14, 2003

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.

THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

If you have any questions, please contact the Privacy Office at the address/ phone number listed at the bottom of this notice.

Lakeside Oral & Facial Surgery Institute acts to maintain the privacy of protected health information and provide individuals with notice of the practice’s legal duties and privacy practices with respect to protected health information as described in this Notice and abide by terms of this Notice currently in effect.

CHANGES TO THIS NOTICE:

We may change our policies and this notice at any time. Changes will apply to medical information we already hold, as well as new information held after the changes occurs. Before a policy change affecting the privacy of your medical information e made, we will change this notice and post notice in the waiting area. You can receive a copy of the current notice at any time. If you do not agree with the terms of this notice, you are entitled to notify us.

Uses and Disclosures of Health Information:

We may use and disclose health information about your treatment, payment, and healthcare operations. For example:

TO PROVIDE TREATMENT: Lakeside Oral & Facial Surgery Institute may use your health information to provide care for you and disclose your health information to others who provide care for you.

TO OBTAIN PAYMENT: Lakeside Oral & Facial Surgery Institute may use and disclose your health information to obtain payment for services provides (i.e. submission of claims to insurance companies, additional information requested by insurance companies, discussion of claim with insured party or personal representative, etc).

TO CONDUCT HEALTH CARE OPERATIONS: Lakeside Oral & Facial Surgery Institute may use and disclose health information for its own operations in order to facilitate the function of the doctor and as necessary to provide quality care to all patients.

FOR APPOINTMENT REMINDERS: Lakeside Oral & Facial Surgery Institute may use and disclose health information to contact you as a reminder that you have an appointment for treatment or after care follow-up (such as voice mail messages, postcards, or letters).

FOR TREATMENT ALTERNATIVES: Lakeside Oral & Facial Surgery Institute may use and disclose your health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

TO YOUR FAMILY AND FRIENDS: Lakeside Oral & Facial Surgery Institute may use and disclose your health information to you, as described in the Patient’s 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. We will also use our professionally judgment and our experience with common practice to make reasonable inferences in your best interest.

WHEN LEGALLY REQUIRED: Lakeside Oral & Facial Surgery Institute will disclose your health information when required to do so by Federal, State, or local law.

WHEN THERE ARE RISKS TO PUBLIC HEALTH: Lakeside Oral & Facial Surgery Institute may disclose your health information for following public activities and purposes:

1. To prevent or control disease, injury or disability, report disease, injury, vital events such as birth or death and the conduct of public health surveillance, investigations and interventions.

2. To report adverse events, product defects, to track products or enable product recalls, repairs, and replacements and to conduct post-marketing surveillance and compliance with requirements of the Food and Drug Administration.

3. To notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease.

TO REPORT ABUSE, NEGLECT OF DOMESTIC VIOLENCE: Lakeside Oral & Facial Surgery Institute is allowed to notify government authorities if he believes a patient is the victim of abuse, neglect of domestic violence. The doctor will make this disclosure only when specifically requires or authorized by law or when the patient agrees to the disclosure.

REQUIRED BY LAW: As permitted or required by State law, Lakeside Oral & Facial Surgery Institute may disclose your health information when we are required to do so by law.

BUSINESS ASSOCIATES: Lakeside Oral & Facial Surgery Institute may disclose your medical information to our business associates each of who has entered into a written contract with us regarding the privacy of medical information.

IN EVENT OF A SERIOUS THREAT TO HEALTH OR SAFETY: Lakeside Oral & Facial Surgery Institute may, consistent with applicable law and ethical standards of conduct, disclose your health information if the doctor, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.

AUTHORITIZATION TO USE OR DISCLOSURE OF HEALTH INFORMATION

Other than stated above, Lakeside Oral & Facial Surgery Institute, will not disclose your health information other than with your written authorization. If you or your representative authorizes the doctor to use or disclose your health information, you may revoke that authorization in writing at anytime.

YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION

You have the following rights regarding your health information that Lakeside Oral & Facial Surgery Institute maintains:

RIGHT TO REQUEST RESTRICTIONS: You may request restrictions on certain uses and disclosures of your health information. You have the right to request a limit on doctor’s disclosure of your health information to someone who is involved in your case or the payment of your care. However, the doctor is not required to agree to your request. If you wish to make a request for restrictions, please contact Lakeside Oral & Facial Surgery Institute at Lakeside Oral & Facial Surgery Institute, Evanston Phone Number 847-328-8899.

RIGHT TO RECEIVE CONFIDENTIAL COMMUNICATIONS: You have the right to request Lakeside Oral & Facial Surgery Institute communicate with you in a certain way. For example, you may ask that the doctor conduct communications pertaining to your health information with you privately with no other family members present. If you wish to receive confidential communications, please contact Lakeside Oral & Facial Surgery Institute at Lakeside Oral & Facial Surgery Institute, Evanston Phone Number 847-328-8899.

RIGHT TO INSPECT AND COPY YOUR HEALTH INFORMATION: You have the right to inspect and copy your health information, including billing records. A request to inspect and copy records containing your health information may be made to Lakeside Oral & Facial Surgery Institute at Lakeside Oral & Facial Surgery Institute, Evanston Phone Number 847-328-8899. If you request a copy of your health information, Provider may charge a reasonable fee for copying and assembling costs associated with your request.

RIGHT TO AMEND YOUR HEALTH INFORMATION: You or your representative have the right to request Lakeside Oral & Facial Surgery Institute amend your records, if you believe your health information records are incorrect or incomplete. That request may be made as long as doctor maintains the information. Doctor may deny the request if it is not in writing or does not include a reason for the amendment. The request may also be denied if the doctor did not create your health records, if the records you are requesting are not part of the Doctor’s records.

RIGHT TO AN ACCOUNTING: You or your representative have the right to request an accounting of disclosures of your health information made by the doctor for certain purposes of authorized by law and certain research. The request for an accounting must be made in writing to Lakeside Oral & Facial Surgery Institute. The request should specify the time period for the accounting starting on 04/14/2003. Accounting requests may not be made for periods of time excess of six (6) years. Doctor will provide the first accounting you request during any 12-month period without charge. Subsequent accounting requests may be subject to a reasonable cost-based fee.

COMPLAINTS

1. You or your representative has the right to express complaints to the Provider and to the Secretary of Health and Human Services if you or your representative believes that your privacy rights have been violated.

2. Any complaints to the Provider should be made in writing to Lakeside Oral & Facial Surgery Institute.

CONTACT PERSONS

If you are concerned about your privacy rights you may contact our privacy officers:

Alan A. Harvey, DMD Lakeside Oral & Facial Surgery Institute, Evanston Phone Number 847-328-8899

Lucy M. Barone, M.A. Lakeside Oral & Facial Surgery Institute, Evanston Phone Number 847-328-8899