Your Rights

Your rights with respect to your protected health information and how you may exercise those rights are outlined below:

You have a right to obtain a copy of or inspect your protected health information: Protected health information includes treatment records, billing records and any other records used by us to make decisions about your treat­ment. A reasonable cost-based fee will be charged for expenses such as staff time, copies and postage. Contact us as indicated at the end of this Notice to obtain information about our fees or if you have any questions about your access.

You have a right to request a restriction on the use and disclosure of your protected health information: You may ask us not to use or disclose some part of your protected health information for the purposes of treatment, payment or operations. You may also request that we not disclose some part of your information to family members and others who may be involved in your care or for notification pur­poses as otherwise described in this Notice. You may request a restriction by sending your request in writing to our Privacy Contact at our office’s address. Although we are not required to agree to the restriction, we will review the request and notify you of our decision. If accepted, we are legally obligated to abide by the restriction.

You have a right to request receipt of confidential communications by alternative means or at an alternative location: We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the
request. Please make this request in writing to our Privacy
Contact.

You may have the right to request an amendment to your protected health information: You may request that we amend protected health information about you. Your re­quest must be in writing with an explanation as to why the information should be amended. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information: It excludes disclosures for treatment, payment or healthcare operations as described in this Notice of Privacy Practices, to you, to family members or friends involved in your care, or notification purposes” or as a result of an authorization signed by you. You have the right to receive specific information regarding these disclo­sures that occurred after September 23, 2013, for up to the previous six years. You may request a shorter timeframe. The right to receive this information is subject to certain exceptions, restrictions and limitations. If you request an accounting more than once in a 12-month period, we will charge you a reasonable cost-based fee for responding to the additional request.

Right to Notification of a Breach: You will receive notifications of breaches of your unsecured protected health information as required by law.
You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice electronically.

Questions and Complaints

If you have any questions, concerns or want more informa­tion about our privacy practices please contact us using the information below.
If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. To file a complaint with us, document the complaint and send it to the HIPAA Privacy Contact at the address noted below. We support your right to the privacy of your protected health information and we will not penalize you for filing a com­plaint.

Contact Our Office:
HIPAA Privacy Contact Dr. Christopher S. Lea D.D.S., P.C.
Dr. John Green II, D.D.S.
Dr. Eric T. Ashley, D.D.S.

10220 Ford Ave. Richmond Hill, GA 31324, Phone Richmond Hill Phone Number 912-756-5960
111 E. Mills Ave, Hinesville GA, 31313,Phone (912)Hinesville - Liberty Trail Phone Number 912-463-4405
1804 Frederica Rd. Ste B, St.Simons GA, 31522 (912)Richmond Hill Phone Number 912-756-5960

This notice was published and becomes effective on September 23, 2013,

Dr. Christopher S. Lea D.D.S., PC
Dr. John Green II, D.D.S.
Dr. Eric T. Ashley, D.D.S.

10220 Ford Ave. Richmond Hill, GA, 31324
111 E. Mills Ave, Hinesville GA, 31313
1804 Frederica Rd.Ste B, St.Simons Island GA, 31522

NOTICE OF PRIVACY PRACTICES

This Notice describes how health 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.
We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 09/23/2013, and will remain in effect until we replace it.

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, and to make new Notice provisions effective for all protected health information that we maintain. When we make a significant change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at our practice location, and we will provide copies of the new Notice upon request.

You may 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

Treatment: We may use and disclose your health information for your treatment. For example, we may disclose your health information to a specialist providing treatment to you.

Payment: We may use and disclose your health information to obtain reimbursement for the treatment and services you receive from us or another entity involved with your care. Payment activities include billing, collections, claims management, and determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party. For example, we may send claims to your dental health plan containing certain health information.

Healthcare Operations: We will use and disclose your pro­tected health Information to conduct the business activities of this office. These activities include, but are not limited to, quality assessment and improvement activities, review of the performance and qualifications of employees, evaluating practitioner and provider performance, conducting training programs, accreditation, certifications, licensing or credentialing activities.

We will share your protected health information with busi­ness associates that perform Specific functions for our prac­tice such as billing. When a business arrangement of this type requires the use of your information, we will have a written contract with the third party to the privacy of your protected health information.

We will call you by name in the waiting room when we are ready to begin your treatment. We will leave messages on answering machines, on voicemail, or with family members reminding you of appointments. We will send letters reminding you of certain appointments or the need to make certain appoint­ments.

Individuals Involved in Your Care or Payment for Your Care: We may disclose your health information to your family or friends or any other individual identified by you when they are involved in your care or in the payment for your care. Additionally, we may disclose information about you to a patient representative. If a person has the authority by law to make health care decisions for you, we will treat that patient representative the same way we would treat you with respect to your health information.

If you are present before the use or disclosure of you protected health information, we will provide you with the opportunity to object to such uses or disclosures. Finally, we may use or disclose your protected health information to an authorized public or private entity to help in disaster relief efforts and to coordinate uses and disclosures to family members or others involved in your health care.

Emergencies: If you are incapacitated or in emergency circumstances, we may use or disclose your protected health information to treat you.

Disaster Relief: We may use or disclose your health information to assist in disaster relief efforts.

Uses and Disclosures of Protected Health Information Based upon Your Written Authorization:

Other uses and disclosures of your protected health infor­mation will be made only with your written authorization unless otherwise permitted or required by law as described below. You may revoke this authorization, at any time, in writing, except to the extent that an action has already been taken based on the authorization.

Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Op­portunity to Object

We may use or disclose your protected health information in the following situations without your consent or authoriza­tion:

Required by Law or for Public Health Activities: We will disclose your protected health information when required by federal, state or local law. Examples of such mandatory disclosures include notifying state or local health authorities regarding particular communicable diseases or providing protected health information to a governmental or regulatory agency with health care oversight responsibilities. If authorized by law, we may disclose your protected health information to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition. We may release pro­tected health information to a coroner or medical examiner to assist in identifying a deceased individual or to determine the cause of death.

Legal Proceedings: We may disclose protected health information in the course of any judicial or administrative proceeding, in response to an order of a court or adminis­trative tribunal (to the extent such disclosure is expressly authorized), under certain conditions in response to a sub-poena, discovery request or other lawful process. We may disclose protected health information to any governmental agency or regulator with whom you have filed a complaint or as part of a regulatory agency examination.

Law Enforcement or Specific Government Functions: We may disclose protected health information in response to a request by a law enforcement official made through a court order, subpoena, warrant, summons or similar process. We may disclose protected health information about you to federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Threat to Health or Safety: We may disclose protected health information to avert a serious threat to someone’s health or safety. This includes reporting suspected abuse neglect or domestic violence to the governmental entity or agency authorized to receive such information and will be made consistent with the requirements of applicable federal and state laws.

Workers’ Compensation: We may disclose your protected health information as authorized to comply with workers’ compensation laws and other similar legally established programs.

Inmates: We may use or disclose your protected health information if you are an inmate of a correctional facility and your physician created or received your protected health information in the course of providing care to you.

Research: We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information.