THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.

USE AND DISCLOSURE OF HEALTH INFORMATION:

Dr. Sanfelippo may use your health information, that is, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996, for purposes of providing you treatment, obtaining payment for your care and conducting health care operations. Dr. Sanfelippo has established a policy to guard against unnecessary disclosure of your health information.

THE FOLLOWING IS A SUMMARY OF THE CIRCUMSTANCES UNDER WHICH AND PURPOSES FOR WHICH YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED.

 

To Provide Treatment. Dr. Sanfelippo may use your health information to provide care for you and disclose your health information to others who provide care to you. For example: our labs, specialist such as orthodontist, periodontist, endodontist, prostodontist,oral surgeon or your physician.

To Obtain Payment. Dr. Sanfelippo any include your health information in invoices to collect payment from third parties for the care you may receive from the doctor. For example, doctor may be required by your Dental/Health Insurance Company to provide information regarding your dental care status so that the insurer will reimburse you or doctor. The doctor also may need to obtain prior approval from your insurer and may need to explain to the insurer your need for the dental care and the services that will be provided to you.

To Conduct Health Care Operations. Dr. Sanfelippo 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 of doctorís patients. Health care operations include activities such as: Activities designed to improve health or reduce health care costs. Contacting healthcare providers and patients with information about treatment alternatives and other related functions that do not include treatment. Training programs including those in which students, trainees or practitioners in health care learn under supervision. Accreditations, certification, licensing or credentialing activities. Review and auditing, including compliance reviews, medical reviews, legal services and compliance programs. For example Dr. Sanfelippo may use your health information to evaluate its staff performance, disclose your health information to Dr.ís staff and contracted personnel for training purposes or use your health information to contact you as a reminder regarding a visit.

For Appointment Reminders. Dr. Sanfelippo may use and disclose your health information to contact you as a reminder that you have an appointment for treatment or dental care with the Doctor.

For Treatment Alternatives. Dr. Sanfelippo 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.

When Legally Required. Dr. Sanfelippo will disclose your health information when required to do so by Federal, State or local law.

When There Are Risks to Public Health. Dr Sanfelippo may disclose your health information for the following public activities and purposes:

    1. To prevent or control disease, injury or disability, report desease, 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.
    4. To an employer about an individual who is a member of the workforce as legally required.

To Report Abuse, Neglect of Domestic Violence. Dr. Sanfelippo is allowed to notify government authorities if he believes a patient is the

victim of abuse, neglect or domestic violence. The doctor will make this disclosure only when specifically requires or authorized by law or when the patient agrees to the disclosure.

In Connection with Judicial and Administrative Proceedings. As permitted or required by State law, Dr. Sanfelippo may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena, discovery request or other lawful process, but only when the doctor makes reasonable efforts to either notify you about the request or to obtain an order protecting your health information.

For Law Enforcement Purposes. As permitted or required by State law, Dr. Sanfelippo may disclose your health information to a law enforcement official for certain law enforcement purposes, including, under certain limited circumstances, if you are a victim of a crime or in order to report a crime.

To Coroners and Medical Examiners. Dr. Sanfelippo may disclose your health information to coroners and medical examiners for purposes of determining your cause of death or for other duties, as authorized by law.

To Funeral Directors. Dr. Sanfelippo may disclose your health information to funeral directors consistent with applicable law and if necessary, to carry out their duties with respect to your funeral arrangements. If necessary to carry out their duties,

The doctor may disclose your health information prior to, and in reasonable anticipation of, your death.

For Organ, Eye or Tissue Donation. Dr. Sanfelippo may use or disclose your health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs, eyes or tissue for the purpose of facilitating the donation and transplantation.

For Research Purposes. Dr. Sanfelippo may, under very select circumstances, use your health information for research. Before the doctor discloses any of your health information for such research purposes, the project will be subject to an extensive approval process.

In Event of a Serious Threat to Health or Safety. Dr. Sanfelippo 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.

For Specific Government Functions. In certain circumstances, the federal regulations authorize the doctor to use or disclose your health information to facilitate specified government functions relating to the military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations and inmates and law enforcement custody.

For Workerís Compensation. Dr. Sanfelippo may release your health information for workerís compensation or similar programs.

AUTHORIZATION TO USE OR DISCLOSE HEALTH INFORMATION

Other than stated above, Dr. Sanfelippo will not disclose your health information other then 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 any time.

YOUR RIGHTS WITH RESPECT TO YOUR HEALTH INFORMATION

You have the following rights regarding your health information that Dr. Sanfelippo 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 doctorís disclosure of your health information to someone who is involved in your care 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 Dr. Sanfelippo at 262-886-6411.

Right to Receive Confidential Communications. You have the right to request that Dr. Sanfelippo communicate with you in a certain way. For example, you may ask that the doctor only 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 Dr. Sanfelippo at 262-886-6411.

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 Dr. Sanfelippo at 262-886-6411. 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 that Dr. Sanfelippo 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. A request for an amendment of records must be made in writing to Dr. Sanfelippo at 5814 Washington Ave., Racine, WI 53406. 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 your health information records were not created by the doctor, if the records you are requesting are not part of the Doctors records, if the health information you wish to amend is not part of the health information you or your representative are permitted to inspect and copy, or if in the opinion of the doctor, the records containing your health information are accurate and complete.

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 authorized by law and certain research. The request for an accounting must be made in writing to Dr. Sanfelippo at 5816 Washington Ave., Racine, WI 53406. The request should specify the time period for the accounting starting on 4/14/2003. Accounting requests may not be made for periods of time in 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.

Right to a Paper Copy of this Notice. You or your representative have a right to a separate paper copy of this notice at any time even if you or your representative have received this notice previously. To obtain a separate paper copy, please contact Dr. Sanfelippo at 262-886-6411 or you may obtain a copy of the current version of Providerís Notice at website, www.drjoesanfelippo.com.

DUTIES OF PROVIDER

Provider is required by law to maintain the privacy of your health information and to provide to you and your representative this Notice of itís duties and privacy practices. Provider is required to abide by the terms of this Notice as may be amended from time to time. Provider reserves the right to change the terms of this Notice and to make the new Notice provisions effective for all health information that it maintains. If provider makes a material change to this Notice, Provider will provide a copy of the revised Notice to you or your appointed representative. You or your representative have the right to express complaints to provider and to the Secretary of Health and Human Services if you or your representative believe that your privacy rights have been violated. Any complaints to provider should be made in writing ot Dr. Sanfelippo at 5814 Washington Ave., Racine,WI 53406. Provider encourages you to express any concerns you may have regarding the privacy of you information. You will not be retaliated against in any way for filing a complaint.

CONTACT PERSON

Dr. Joseph Sanfelippo is the contact person for all issues regarding patient privacy and your rights under the Federal privacy standards. You may contact him at 5814 Washington Ave., Racine, WI 53406 or by phone 262-886-6411.

EFFECTIVE DATE

This notice is effective April 14, 2003.

IF YOU HAVE ANY QUESTIONS REGARDING THIS NOTICE, PLEASE CONTACT THE OFFICE OF DR. JOSEPH SANFELIPPO