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The information contained here should be used in consultation
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medical or dental advice to anyone. Dr. Gaurav Agarwal
is licensed to practice in the state of Virginia and this web
site is not intended to solicit patients from other states.
Further, this web site and Dr. Gaurav Agarwal take no responsibility
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HEALTH INFORMATION PRIVACY
POLICIES & PROCEDURES
These Health Information Privacy Policies
& Procedures implement our obligations to protect the privacy
of individually identifiable health information that we create,
receive, or maintain as a healthcare provider.
We implement these Health Information
Privacy Policies and Procedures as a matter of sound business
practice; to protect the interests of our patients; and to fulfill
our legal obligations under the Health Insurance Portability
and Accountability Act of 1996 ("HIPAA"), its implementing
regulations at 45 CFR Parts 160 and 164 (65 Fed. Reg 82462 (Dec.
28, 2000)) ("Privacy Rules"), as amended (67 Fed. Reg.
53182 [Aug. 14, 2002]), and state law that provides greater protection
or rights to patients than the Privacy Rules.
As a member of our workforce or as
our Business Associate, you are obligated to follow these Health
Information Privacy Policies & Procedures faithfully. Failure
to do so can result in disciplinary action, including termination
of your employment or affiliation with us.
These Policies & Procedures address
the basics of HIPAA and the Privacy Rules that apply in our dental
practice. They do not attempt to cover everything in the Privacy
Rules. The Policies & Procedures sometimes refer to forms
we use to help implement the policies and to the Privacy Rules
themselves when added detail may be needed.
Please note that while the Privacy
Rules speak in terms of "individual" rights and actions,
these Policies & Procedures use the more familiar word "patient"
instead; "patient" should be read broadly to include
prospective patients, patients of record, former patients, their
authorized representatives, and any other "individuals"
contemplated in the Privacy Rules.
If you have questions or doubts about
any use or disclosure of individually identifiable health information
or about your other obligations under these Health Information
Privacy Policies & Procedures, the Privacy Rules or other
federal or state law, please contact our office. This policy
was adopted effective 10/09/2008.
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1. General Rule: No Use or Disclosure
Our dental office must not use or disclose
protected health information (PHI), except as these Privacy
Policies & Procedures permit or require.
2. Acknowledgement and Optional Consent
Our dental office will make a good
faith effort to obtain a written acknowledgement of receipt of
our Notice of Privacy Practices (see Section 9) from a
patient before we use or disclose his or her protected health
information (PHI) for treatment, to obtain payment for that treatment,
or for our healthcare operations (TPO).
Our dental office’s use or disclosure
of PHI for our payment activities and healthcare operations may
be subject to the minimum necessary requirements (see Section
7).
Our dental office will become familiar
with our state’s privacy laws. If required by our state
law, or as directed by the dentist, we will also seek Consent
from a patient before we use or disclose PHI for TPO purposes
– in addition to obtaining an Acknowledgement of receipt
of our Notice of Privacy Practices.
a) Obtaining Consent – If consent is to be obtained,
upon the individual’s first visit as a patient (or next
visit if already a patient), our dental office will request and
obtain the patient’s written Consent for our use
and disclosure of the patient’s PHI for treatment, payment,
and healthcare operations.
Any consent we obtain must be on our
Consent form, which we may not alter in any way. Our dental
office will include the signed Consent form in the patient’s
chart.
b)
Exceptions – Our dental office does not have to obtain
the patient’s Consent in emergency treatment situations;
when treatment is required by law; or when communications barriers
prevent consent.
c)
Consent Revocation – A patient from whom we obtain
consent may revoke it at any time by written notice. Our dental
office will include the revocation in the patient’s chart.
There is space at the bottom of our Consent form where
the patient can revoke the consent.
d) Applicability – Consent for use or disclosure
of PHI should not be confused with informed consent for dental
treatment. This section applies to our practice.
3. Authorization
In some cases we must have proper,
written Authorization from the patient (or the patient’s
personal representative) before we use or disclose a patient’s
PHI for any purpose (except for TPO purposes) or as permitted
or required without consent or authorization (see Sections 3,
4, or 5).
Our dental office will use the Authorization
form. We will always act in strict accordance with an Authorization.
a)
Authorization Revocation – A patient may revoke an
authorization at any time by written notice. Our dental office
will not rely on an Authorization we know has been revoked.
b)
Authorization from Another Provider – Our dental
office will use or disclose PHI as permitted by a valid Authorization
we receive from another healthcare provider.
Our dental office may rely on that
covered entity to have requested only the minimum necessary protected
PHI. Therefore, our dental office will not make our own "minimum
necessary" determination, unless we know that the Authorization
is incomplete, contains false information, has been revoked,
or has expired.
c)
Authorization Expiration – Our dental office will
not rely on an Authorization we know has expired.
4. Oral Agreement
Our dental office may use or disclose
a patient’s PHI with the patient’s Oral Agreement
or if the patient is unavailable subject to all applicable requirements.
Our dental office may use professional
judgment and our experience with common practice to make reasonable
inferences of the patient’s best interest in allowing a
person to act on behalf of the patient to pick up dental/medical
supplies, X-rays, or other similar forms of PHI.
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5. Permitted Without Acknowledgement,
Consent Authorization or Oral Agreement
Our dental office may use or disclose
a patient’s PHI in certain situations, without Authorization
or Oral Agreement. In our dental office, these disclosures
are not likely to be frequent.
a) Verification of Identity – Our dental office will always
verify the identity of any patient, and the identity and authority
of any patient’s personal representative, government or
law enforcement official, or other person, unknown to us, who
requests PHI before we will disclose the PHI to that person.
Our dental office will obtain appropriate
identification and, if the person is not the patient, evidence
of authority. Examples of appropriate identification include
photographic identification card, government identification card
or badge, and appropriate document on government letterhead.
Our dental office will document the incident and how we responded.
b)
Uses or Disclosures Permitted under this Section 5 –
The situations in which our dental office is permitted to use
or disclose PHI in accordance with the procedures set out in
this Section 5 are listed below.
- Our dental office may disclose a patient’s
PHI to that patient on request.
- Our dental office may disclose to a
patient’s personal representative PHI relevant to the representative
capacity. We will not disclose to a personal representative we
reasonably believe may be abusive to a patient any PHI we reasonably
believe may promote or further such abuse.
- Our dental office will not use or disclose
a patient’s PHI for fundraising purposes without the patient’s
Authorization.
- Our dental office will not use or disclose
PHI for marketing without a patient’s Authorization
unless the marketing is in the form of a promotional gift of
nominal value that we provide, or face-to-face communications
between us and the patient.
- Our dental office may use or disclose
PHI in the following types of situations, provided procedures
specified in the Privacy Rules are followed:
- For public health activities;
- To health oversight agencies;
- To coroners, medical examiners, and
funeral directors;
- To employers regarding work-related
illness or injury;
- To the military;
- To federal officials for lawful intelligence,
counterintelligence, and national security activities;
- To correctional institutions regarding
inmates;
- In response to subpoenas and other
lawful judicial processes;
- To law enforcement officials;
- To report abuse, neglect, or domestic
violence;
- As required by law;
- As part of research projects; and
- As authorized by state worker’s
compensation laws.
6. Required Disclosures
Our dental office will disclose protected
health information (PHI) to a patient (or to the patient’s
personal representative) to the extent that the patient has a
right of access to the PHI (see Section 10); and to the U.S.
Department of Health and Human Services (HHS) on request for
complaint investigation or compliance review.
Our dental office will use the disclosure
log to document each disclosure we make to HHS.
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7. Minimum Necessary
Our dental office will make reasonable
efforts to disclose, or request of another covered entity, only
the minimum necessary protected health information (PHI)
to accomplish the intended purpose.
There is no minimum necessary
requirement for disclosures to or requests by one another in
our dental office or by a healthcare provider for treatment;
permitted or required disclosures to, or for disclosure requested
and authorized by, a patient; disclosures to HHS for compliance
reviews or complaint investigations; disclosures required by
law; or uses or disclosures required for compliance with the
HIPAA Administrative Simplification Rules.
a) Routine or Recurring Requests or
Disclosures –
Our dental office will follow the policies and procedures that
we adopt to limit our routine or recurring requests for our disclosures
of PHI to the minimum reasonably necessary for the purpose.
b) Non-Routine or Non-Recurring Requests
or Disclosures –
No non-routine or non-recurring request for or disclosure of
PHI will be made until it has been reviewed on a patient-by-patient
basis against our criteria to ensure that only the minimum necessary
PHI for the purpose is requested or disclosed.
c) Other’s Requests – Our dental office will rely,
if reasonable for the situation, on a request to disclose PHI
being for the minimum necessary, if the requester is: (a) a covered
entity; (b) a professional (including an attorney or accountant)
who provides professional services to our practice, either as
a member of our workforce or as our Business Associate,
and who represents that the requested information is the minimum
necessary; (c) a public official who represents that the information
requested is the minimum necessary; or (d) a researcher presenting
appropriate documentation or making appropriate representations
that the research satisfies the applicable requirements of the
Privacy Rules.
d) Entire Record – Our dental office will not use, disclose,
or request an entire record, except as permitted in these Policies
& Procedures or standard protocols that we adopt reflecting
situations when it is necessary.
e) Minimum Necessary Workforce Use – Our dental office will use
only the minimum necessary PHI needed to perform our duties.
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8. Business Associates
Our dental office will obtain satisfactory
assurance in the form of a written contract that our Business
Associates will appropriately safeguard and limit their use
and disclosure of the protected health information (PHI) we disclose
to them.
These Business Associate requirements
are not applicable to our disclosures to a healthcare provider
for treatment purposes. The Business Associate Contract Terms
document contains the terms that federal law requires be included
in each Business Associate Contract.
a.) Breach by Business Associate – If our dental office learns
that a Business Associate has materially breached or violated
its Business Associate Contract with us, we will take
prompt, reasonable steps to see that the breach or violation
is cured.
If the Business Associate does
not promptly and effectively cure the breach or violation, we
will terminate our contract with the Business Associate,
or if contract termination is not feasible, report the Business
Associate’s breach or violation to the U.S. Department
of Health and Human Services (HHS).
9. Notice of Privacy Practices
Our dental office will maintain a Notice
of Privacy Practices as required by the Privacy Rules.
a) Our Notice – Our dental office will use and disclose
PHI only in conformance with the contents of our Notice of
Privacy Practices. We will promptly revise a Notice of
Privacy Practices whenever there is a material change to
our uses or disclosures of PHI to legal duties, to the patients’
rights or to other privacy practices that render the statements
in that Notice no longer accurate.
Form 1, Notice of Privacy Practices,
found in this Privacy Kit, contains the terms that federal law
requires.
b) Distribution of Our Notice – Our dental office will provide
our Notice of Privacy Practices to any person who requests
it, and to each patient no later than the date of our first service
delivery.
Our dental office will have our Notice
of Privacy Practices available for patients to take with
them. We will also post our Notice of Privacy Practices
in a clear and prominent location where it is reasonable to expect
patients seeking services from us will be able to read the Notice.
c) Acknowledgement of Notice – Our dental office will make
a good faith effort to obtain from the patient a written Acknowledgement
of receipt of our Notice of Privacy Practices.
Our dental office shall use Form 2,
Acknowledgement of Receipt of Notice of Privacy Practices,
found in this Privacy Kit, to obtain the Acknowledgement. If
we cannot obtain written Acknowledgement from the patient, we
will use the form to document our attempt and the reason why
written Acknowledgement was not signed by the patient.
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10. Patients’ Rights
Our dental office will honor the rights
of patients regarding their PHI.
a) Access – With rare exceptions, our dental office
must permit patients to request access to the PHI we or our Business
Associates hold.
No PHI will be withheld from a patient
seeking access unless we confirm that the information may be
withheld according to the Privacy Rules. We may offer to provide
a summary of the information in the chart. The patient must agree
in advance to receive a summary and to any fee we will charge
for providing the summary. Our dental office will contact our
Business Associates to retrieve any PHI they may have
on the patient.
b) Amendment – Patients have the right to request to
amend their PHI and other records for as long as our dental office
maintains them.
Our dental office may deny a request
to amend PHI or records if: (a) we did not create the information
(unless the patient provides us a reasonable basis to believe
that the originator is not available to act on a request to amend);
(b) we believe the information is accurate and complete; or (c)
we do not have the information.
Our dental office will follow all procedures
required by the Privacy Rules for denial or approval of amendment
requests. We will not, however, physically alter or delete existing
notes in a patient’s chart. We will inform the patient when
we agree to make an amendment, and we will contact our Business
Associates to help assure that any PHI they have on the patient
is appropriately amended. We will contact any individuals whom
the patient requests we alert to any amendment to the patient’s
PHI. We will also contact any individuals or entities of which
we are aware that we have sent erroneous or incomplete information
and who may have acted on the erroneous or incomplete information
to the detriment of the patient.
When we deny a request for an amendment,
we will mark any future disclosures of the contested information
in a way acknowledging the contest.
c) Disclosure Accounting – Patients have the right
to an accounting of certain disclosures our dental office made
of their PHI within the 6 years prior to their request. Each
disclosure we make, that is not for treatment payment or healthcare
operations, must be documented showing the date of the disclosure,
what was disclosed, the purpose of the disclosure, and the name
and (if known) address of each person or entity to whom the disclosure
was made. The Authorization or other documentation must
be included in the patient’s record. We use the patient’s
chart to track each disclosure of PHI as needed to enable us
to fulfill our obligation to account for these disclosures.
We are not required to account for
disclosures we made: (a) before October 9, 2008; (b) to the patient
(or the patient’s personal representative); (c) to or for
notification of persons involved in a patient’s healthcare
or payment for healthcare; (d) for treatment, payment, or healthcare
operations; (e) for national security or intelligence purposes;
(f) to correctional institutions or law enforcement officials
regarding inmates; or (g) according to an Authorization signed
by the patient or the patient’s representative; (h) incident
to another permitted or required use disclosure.
We will temporarily suspend the accounting
of any disclosure when requested to do so pursuant according
to the Privacy Rules by health oversight agencies or law enforcement
officials. We may charge for any accounting that is more frequent
than every 12 months, provided the patient is informed of the
fee before the accounting is provided. We will contact our Business
Associates to assure we include in the accounting any disclosures
made by them for which we must account.
d) Restriction on Use or Disclosure – Patients have the right to
request our dental office to restrict use or disclosure of their
PHI, including for treatment, payment, or healthcare operations.
We have no obligation to agree to the request, but if we do,
we will comply with our agreement (except in an appropriate dental/medical
emergency).
We may terminate an agreement restricting
use or disclosure of PHI by a written notice of termination to
the patient. We will contact our Business Associates whenever
we agree to such a restriction to inform the Business Associate
of the restriction and its obligations to abide by the restriction.
We will document in the patient’s chart any such agreed
to restrictions.
e) Alternative Communications – Patients have the right to request
us to use alternative means or alternative locations when communicating
PHI to them. Our dental office will accommodate a patient’s
request for such alternative communications if the request is
reasonable and in writing.
Our dental office will inform the patient
of our decision to accommodate or deny such a request. If we
agree to such a request, we will inform our Business Associates
of the agreement and provide them with the information necessary
to comply with the agreement.
f) Applicability – Our dental office will be aware of and
respect these patients’ rights regarding their PHI, even
though in most situations patients are unlikely to exercise them.
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11. Staff Training and Management,
Complaint Procedures, Data Safeguards, Administrative Practices
a) Staff Training and Management
* Training – Our dental office will train all members
of our workforce in these Privacy Policies & Procedures,
as necessary and appropriate for them to carry out their functions.
We will complete the privacy training of our existing workforce
by October 9, 2008.
After October 9, 2008, our dental office
will train each new staff member within a reasonable time after
the member starts. We will also retain each staff member whose
functions are affected either by a material change in our Privacy
Policies and Procedures or in the member’s job functions,
within a reasonable time after the change.
Form 7, Staff Review of Policies
and Procedures, can be used to have workforce members acknowledge
they have received and read a copy of these Policies and Procedures.
*Discipline and Mitigation – Our dental office will develop,
document, disseminate, and implement appropriate discipline policies
for staff members who violate our Privacy Policies & Procedures,
the Privacy Rules, or other applicable federal or state privacy
law.
Staff members who violate our Privacy
Policies & Procedures, the Privacy Rules or other applicable
federal or state privacy law will be subject to disciplinary
action, possibly up to and including termination of employment.
b) Complaints – Our dental office will implement procedures
for patients to complain about our compliance with our Privacy
Policies and Procedures or the Privacy Rules. We will also implement
procedures to investigate and resolve such complaints.
The Complaint form can be used
by the patient to lodge the complaint. Each complaint received
must be referred to management immediately for investigation
and resolution. We will not retaliate against any patient or
workforce member who files a Complaint in good faith.
c) Data Safeguards – Our dental office will "add
to" and strengthen these Privacy Policies & Procedures
with such additional data security policies and procedures as
are needed to have reasonable and appropriate administrative,
technical, and physical safeguards in place to ensure the integrity
and confidentiality of the PHI we maintain.
Our dental office will take reasonable
steps to limit incidental uses and disclosures of PHI made according
to an otherwise permitted or required use or disclosure.
d) Documentation and Record Retention – Our dental office will maintain
in written or electronic form all documentation required by the
Privacy Rules for six years from the date of creation or when
the document was last in effect, whichever is greater.
e) Privacy Policies & Procedures – Only Dr. Gaurav Agarwal may
change these Privacy Policies & Procedures.
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12. State Law Compliance
Our dental office will comply with
the privacy laws of each state that has jurisdiction over our
practice, or its actions involving protected health information
(PHI), that provide greater protections or rights to patients
than the Privacy Rules.
13. HHS Enforcement
Our dental office will give the U.S.
Department of Health and Human Services (HHS) access to our facilities,
books, records, accounts, and other information sources (including
individually identifiable health information without patient
authorization or notice) during normal business hours (or at
other times without notice if HHS presents appropriate lawful
administrative or judicial process).
We will cooperate with any compliance
review or complaint investigation by HHS, while preserving the
rights of our practice.
14. Designated Personnel
Our dental office will designate a
Privacy Officer and other responsible persons as required by
the Privacy Rules.
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2008 Gaurav Agarwal, D.D.S., M.S.D., P.L.L.C. All Rights Reserved.
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