Randall H. Hiers, D.D.S., P.A.
Eastern Shore Smile Solutions
Notice of Privacy Practices
This notice describes how health information about you may be used and disclosed and your rights for access to
same. 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 take
effect (04/14/03), and will remain in effect unless it is replaced. 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 my 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 Operation: We may use and disclose your health information in connection with our healthcare operation.
Healthcare operations include quality assessment and improvement activities, reviewing the competence or
qualification 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 operation,
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 judgement disclosing only health information that is directly relevant to the person’s involvement in your
healthcare. We will also use our professional judgement and our experience with common practice to make reasonable
inference 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 communication 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 of the health or safety of
others.
National Security: We may disclose to military authorities the health information of Armed Forces personnel under
certain circumstance. We may disclose to authorize federal officials health information required for lawful intelligence,
counterintelligence, and other national security activities. We may disclose to correctional institution of law
enforcement official having lawful custody of protected health information of inmate or patient under certain
circumstance.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders
(such as voicemail message, 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 $1.00 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
alternate 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 for 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 purposed 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 e 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 circumstance.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practice or have questions or concerns, please contact us.
If you are concern that we may have violated your privacy rights, or if 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 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 may also submit a written complain 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:
Christopher Hiers, 29276 Erickson Dr., Easton, MD 21601
Phone: 410-228-4191
Email: info@easternshoresmilesolutions.com
Fax: 877-712-4781