This notice describes how medical information about you may be used and disclosed and how you can obtain access to this information. Please review this information carefully.

Associates in Dentistry - Charles L. Kincaid DDS PA

400 East 23rd Street

P.O. Box 3745

Lawrence, KS 66046-0745

(785)843-4333

Notice of Privacy Practices for Protected Health Information

EFFECTIVE APRIL 14, 2003 - REVISED SEPTEMBER 23, 2013

Associates in Dentistry-Charles L. Kincaid DDS PA dentists and staff create, obtain, maintain, and destroy protected health information regarding each patient as we provide our services to you. This protected health information may include documentation of your symptoms, examination and test results, diagnoses, treatment, and plans of future treatment. It also includes billing documents for those services. Federal privacy laws permit our office to make uses and disclosures of your information for certain purposes. The following privacy notice describes how your protected health and dental information may be used and disclosed and how you may gain access to it. Please review it carefully!

Uses and Disclosures

Treatment, Payment, and Healthcare Operations

Associates in Dentistry-Charles L. Kincaid DDS PA may use and disclose your protected health information for treatment, payment and healthcare operations related to the services that we provide you. Some examples of these uses include but are not limited to:

An assistant obtains treatment information about you, records it in your health record, and discusses it with your dentist.

During the course of your treatment, the dentist determines he or she will need to consult with another specialist in the area. He or she will share your protected health information with the specialist to obtain his or her input.

You are seen in the office by one of our physicians and undergo a procedure. We submit a request for payment to your insurance company. The company requests additional information regarded the serviced provided in order to determine payment. We will provide information to them about you and the care given.

The state licensing authority wants to assure that we are acting consistent with the state law regarded the care of our patients. In doing so, it wants sampling, which includes a review of your chart. At the authorities request, we will provide copies of your record to include in the sampling.

Our Uses and Disclosures

We have business associates with whom we may share your protected health and dental information. These associates provide services for us such as billing, accounting, collections, software and hardware maintenance, etc. the information disclosed will be limited to that which is relevant to services the business associate provides.

We may use or disclose your protected health information to notify or assist in notifying a family member, personal representative, or other person responsible for your care about your location, general condition, or death.

We may disclose to a family member, relative, close personal friend, or other person you identify health information relevant to that person’s involvement in your care, in payment for such care, or in an emergency.

We may disclose information to researchers when an institutional review board that has reviewed the proposal and established protocols to ensure the privacy of your protected health information has approved their research.

Your protected health information may be used or disclosed to assist in disaster relief efforts.

We may disclose your protected health information to funeral directors or coroners consistent with applicable law to allow them to carry out their duties.

Consistent with applicable law, we may disclose your protected health information to organ procurement organizations or other entities engaged in the procurement, banking, or transplantation of organs for the purpose of tissue donation and transplant.

We may contact you to provide you with appointment reminders, information about treatment alternatives, information about other health-related benefits and services, or fund raising efforts that may be of interest to you. For example, we may leave appointment reminders on your answering machine or with the person who may answer the telephone at the number that you have provided us in order to contact you.

We may disclose your protected health information relating to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to the FDA to enable product recalls, repairs, or replacements.

If you are seen for an injury and are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation.

We may disclose your protected health information to public health or controlling disease injury, or disability.

We may disclose your protected health information to public authorities as allowed by law to report abuse and neglect.

If you are an inmate of a correctional institution, we may disclose to the institution or agents thereof, your protected health information necessary for your health and the health and safety of other individuals.

We may disclose your protected health information for law enforcement purposes or in the course of any judicial or administrative proceeding as required by law, such as when required by a court order, in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement or as allowed by law with your consent.

We may disclose your protected health information to appropriate health oversight agencies for health oversight activities.

We may disclose your protected health information for specialized government functions as authorized by law such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel.

Consents

In order to use or disclose your protected health and dental information for any reason not listed above, Associates in Dentistry-Charles L. Kincaid DDS PA must receive a signed consent prior to releasing the information. The consent must include a detailing of the information to be disclosed, to whom it will be disclosed, an expiration date of the consent, and your authorizing signature. All authorizations may be revoked in writing except to the extent that the office has already acted on them. The consent form may be requested at the front desk and should be returned to our billing office.

Your Health Information Rights

While the physical health, dental and billing records we maintain are property of Associates in Dentistry-Charles L. Kincaid DDS PA, the information they hold is yours. The following describes your rights regarded that information. You have the right to:

Request additional restriction to how our office uses and discloses your information. This request must be made in writing to the office. Our office is not required to agree to the increase restriction. If the requested restriction interferes in any way with the billing and capture of funds for services provided to you, our office can decline services to you and/or filing insurance claims in your behalf to pay for such services.

Obtain a paper copy of the Notice of Privacy Practices for Protected Health Information. A copy will be given to each patient upon implementation of the privacy practices. Additional copies may be requested at the front desk.

Request that you be allowed to inspect or receive a copy or summary of your health and billing records. The request must be in writing; a form may be picked up from our front desk. The first copy is free of charge. Any additional copies will incur in a fee for copying or receiving a summary of your health and dental record. Fee information may be obtained by contacting our billing office. If the request for access is denied, you may appeal the denial to an independent provider except in certain cases.

Request that your protected health information be amended to correct incomplete or incorrect information. This request must be made in writing. If your request for amendment is denied, you have the right to file a statement of disagreement and require the request for amendment and denial be attached to all future disclosures of your protected health information.

Obtain an accounting of disclosures of your protected health information by delivering a written request to our office or using the form we provide upon request at the front desk. The accounting will not include internal uses of information for treatment, payment, or healthcare operations, disclosures made to you or at your request or consent, or disclosures made to family members or friends in the course of providing care.

Request that communication of your health information be made by alternative means or at an alternative location. This request must be in writing.

Revoke authorizations previously made to disclose information, except to the extent the office has already acted upon them. This revocation must be made in writing and delivered to the office

Our Responsibilities

Associates in Dentistry-Charles L. Kincaid DDS PA is required to:

Maintain the privacy of your health information as required by law.

Provide you with a notice of your duties and privacy practices regarding the information we collect and maintain about you.

Abide by the terms of this Notice.

Respond to any request for access within thirty days and request for increased restrictions or amendment within sixty days.

Accommodate your reasonable requests regarding methods to communicate health information with you.

We reserve the right to amend, change, add or eliminate provisions in our privacy policy within the restrictions of the law. If our policies change, this notice will be updated. A new copy of the notice may be requested at the front desk.

To Request Information or File a Complaint

If you have questions or would like additional information regarding the handling of your information, you may contact Associates in Dentistry-Charles L. Kincaid DDS PA, 400 East 23rd Street, Lawrence, Ks 66046.

If you believe your privacy rights have been violated or have a problem or complaint regarding the handling of your information, you may file a written complaint to our office by delivering it to Claudia Kincaid, Owner and Manager, Associates in Dentistry-Charles L. Kincaid DDS PA 400 East 23rd Street, Lawrence, KS 66046. The complaint will be reviewed and researched and you should receive a response of resolution within sixty days. You may also file a complaint to the Secretary of Health and Human Services at 200 Independence Avenue, SW, Washington, D.C. 20201.

We cannot and will not require you to waive any of the above rights or the right to file a complaint as a condition of receiving treatment from our office.

We cannot and will not retaliate against you for filing a complaint with our office or with the Secretary of Health and Human Services.

Effective Date

This notice goes into effect September 23, 2013. Amends and updates previous notice effective April 14, 2003

Associates in Dentistry – Charles L. Kincaid DDS PA reserves the right to change the terms and conditions at any time, and you agree to accept in accordance by the most recent version of this Terms of Use Agreement each time you view and use this website. You are advised to consult these Terms every time you visit and use the website. Do not use the website if you do not agree to all of the following terms and conditions.

The content in this website is for general information purposes only and does not constitute or is intended to provide advice and should not be relied upon as a substitute for professional dental or medical advice, diagnosis or treatment. We strongly suggest to NOT act upon content or information without seeking appropriate professional advice.

We may provide links on this website to other websites that are not under our control. These links and information about them are provided for reference only. They are not intended as an endorsement by Associates in Dentistry – Charles L. Kincaid DDS PA and does not assume any responsibility of liability for any information, content, communication, services, goods or other materials available on third-party linked sites or for any changes or updates to such sites or any of the individual operating the website or a warranty of any type of the website or related to it.

Taking in consideration the use of this website, you agree that in no event Associates in Dentistry – Charles L. Kincaid DDS PA or its affiliated or related entities, its content providers or any other party involved in creating, producing or delivering this website or any site linked to this website, be responsible or liable to you or entity in any manner whatsoever for any loss, damage, injury, claim, liability or other cause of any kind or character whatsoever based upon or resulting from any information provided in this website or arising from any decision made or action or non-action taken by you or any other person in reliance upon the information provided through this website, even if you advise us of the possibility of any claims or damages. You accept the fact that this website is only providing you with access to content and services and that it disclaims all warranties relating to and any and all liability arising from such content or services.

Associates in Dentistry – Charles L. Kincaid DDS PA has made and will continue to make efforts to include accurate and current information on this website. However the materials in this website are provided “as is” and to the fullest extent permissible pursuant to applicable law. Associates in Dentistry – Charles L. Kincaid DDS PA disclaims all warranties, express or implied, including, without limitation, implied warranties of merchantability and fitness for a particular purpose. Associates in Dentistry – Charles L. Kincaid DDS PA is not responsible for the use you give the materials in the website, as well as not warranting that the functions contained in the materials will be error-free, free of viruses or other harmful components.

Associates in Dentistry – Charles L. Kincaid DDS PA may terminate the Services and access to this website without notice in its sole discretion. In the event of a termination, the disclaimers and limitations of liabilities set forth in this Terms of Service shall survive. Users who violate this Terms of Service may additionally incur criminal and/or civil liability. Associates in Dentistry – Charles L. Kincaid DDS PA will refer violators to civil or criminal authorities for prosecution, and will cooperate fully with applicable government authorities in connection with its investigations of any suspected civil or criminal violations.

The Trademarks appearing in this website, including those of Associates in Dentistry –Charles L. Kincaid DDS PA are property of their respective owners. No logo, graphic, sound image or animation from the website may be copied or imitated in whole or part unless expressly permitted by Associates in Dentistry – Charles L. Kincaid DDS PA.

All materials on this website are copyrighted and are protected under State and Federal law, as well as international treaties and the copyright laws of other countries. Associates in Dentistry – Charles L. Kincaid DDS PA materials may not be reproduced, copied, distributed, adapted, displayed, edited, published, transmitted or downloaded in any way without sole and written permission of Associates in Dentistry – Charles L. Kincaid DDS PA. All rights not expressly granted herein are reserved by Associates in Dentistry – Charles L. Kincaid DDS PA.

You agree to indemnify, defend and hold harmless Associates in Dentistry – Charles L. Kincaid DDS PA, its telecommunication providers and service providers and its subsidiaries, affiliates, officers, directors, employees, consultants and agents, if any, from any and all third-party claims, liability, damages and costs (Including but not limited to: attorney fees or other expenses incurred) due to arising from your use of the Services and/or the website, any content you transmit or relay using the Services or webpage, your violation to the Terms of Service or your infringement of any intellectual property or other right of any person or entity.

The Terms of Use constitutes the entire agreement between the parties with respect to the subject matter hereof and supersedes and replaces all prior or contemporaneous understandings or agreements, written or oral, regarding such subject matter. Any waiver of any provision of the Terms of Service will be effective only if expressly made in writing and signed by Associates in Dentistry – Charles L. Kincaid DDS PA.

NON-DISCRIMINATION POLICY

Associates in Dentistry-Charles L. Kincaid DDS PA dentists and staff complies with applicable Federal Civil Rights Laws and does not and shall not discriminate against people on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, military status, or any other basis prohibited by federal, state, or local law, in any of its activities or operations.

Associates in Dentistry-Charles L. Kincaid DDS PA provides free aids and services to people with disabilities to communicate effectively with us, such as:

-Qualified sign language interpreters

-Written information in other formats (large print, audio, accessible electronic formats, other formats)

-Information written in other languages

If you need these services, please contact Associates in Dentistry at (785)843-4333

If you believe that Associates in Dentistry - Charles L. Kincaid DDS PA has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age disability, or sex, you can file a grievance with: Claudia Kincaid, Office Manager, 400 E 23rd St, Lawrence, KS 66046, Phone: (785)843-4333, Fax:(785)843-1218, E-mail:manager@associatesindentistry.net

You can file a grievance in person or by mail, fax or e-mail. If you need help filing a grievance, Claudia Kincaid is available to help you.

You can also file a civil rights complain with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/cp/complaint_frontpage.jsf or by mail of phone at:

U.S. Department of Health and Human Services

200 Independence Ave, SW

Room 509F, HHH Building

Washington, D.C. 20201

1-800-368-1019, 1-800-537-7697 (TDD)

Complaint Forms are available at: http://www.hhs.gov/ocr/filing-with-ocr/index.html

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