University of the Pacific, Arthur A. Dugoni School of Dentistry must not use or disclose protected health information (PHI), except as these Privacy Policies & Procedures permit or require.

2. Acknowledgement and Optional Consent

The School of Dentistry 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).

The School of Dentistry’s use or disclosure of PHI for our payment activities and healthcare operations may be subject to the minimum necessary requirements (see Section 7).

The School of Dentistry will become familiar with our state’s privacy laws. If required by our state law, or as directed by the supervising 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), the dental school 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. The Pacific School of Dentistry will include the signed Consent form in the patient’s chart.

b)Exceptions – The School of Dentistry 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. The Pacific School of Dentistry 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.

Date: _______________________________

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).

The School of Dentistry 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. The School of Dentistry will not rely on an Authorization we know has been revoked.

b)Authorization from Another Provider – The School of Dentistry will use or disclose PHI as permitted by a valid Authorization we receive from another healthcare provider.

The School of Dentistry may rely on that covered entity to have requested only the minimum necessary protected PHI. Therefore, the School of Dentistry 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 – The School of Dentistry will not rely on an Authorization we know has expired.

4. Oral Agreement

The Pacific School of Dentistry 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.

The Pacific School of Dentistry 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.

5. Permitted Without Acknowledgement, Consent Authorization or Oral Agreement

The School of Dentistry may use or disclose a patient’s PHI in certain situations, without Authorization or Oral Agreement. These disclosures are not likely to be frequent.

a) Verification of Identity – The School of Dentistry 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.

The School of Dentistry 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. The School of Dentistry will document the incident and how we responded.

b)Uses or Disclosures Permitted under this Section 5 – The situations in which the Pacific School of Dentistry is permitted to use or disclose PHI in accordance with the procedures set out in this Section 5 are listed below.

The School of Dentistry may disclose a patient’s PHI to that patient on request.

The School of Dentistry 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.

The School of Dentistry will not use or disclose a patient’s PHI for fundraising purposes without the patient’s Authorization.

The School of Dentistry 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.

The School of Dentistry 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

The School of Dentistry 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.

The School of Dentistry will use the disclosure log to document each disclosure we make to HHS.

7. Minimum Necessary

The School of Dentistry 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 at the School of Dentistry 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 –The School of Dentistry 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 –The School of Dentistry 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 – The School of Dentistry 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 – The School of Dentistry will use only the minimum necessary PHI needed to perform our duties. All students, residents, faculty and staff will exercise reasonable precautions to prevent the unintended disclosure of PHI.

8. Business Associates

The School of Dentistry 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 the School of Dentistry 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

The School of Dentistry will maintain a Notice of Privacy Practices as required by the Privacy Rules.

a) Our Notice – The School of Dentistry 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 – The School of Dentistry 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 after April 14, 2003.

The School of Dentistry 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 – The School of Dentistry will make a good faith effort to obtain from the patient a written Acknowledgement of receipt of our Notice of Privacy Practices.

The School of Dentistry shall use the Form , Acknowledgement of Receipt of Notice of Privacy Practices, 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.

10. Patients’ Rights

The School of Dentistry will honor the rights of patients regarding their PHI.

a) Access – With rare exceptions, the School of Dentistry 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. The School of Dentistry 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 the School of Dentistry maintains them.

The School of Dentistry 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.

The School of Dentistry 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) DisclosureAccounting – Patients have the right to an accounting of certain disclosures the School of Dentistry 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 April 14, 2003; (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; (g) according to an Authorization signed by the patient or the patient’s representative; or (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 the School of Dentistry 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. The School of Dentistry will accommodate a patient’s request for such alternative communications if the request is reasonable and in writing.

The School of Dentistry 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 – The School of Dentistry will be aware of and respect these patients’ rights regarding their PHI, even though in most situations patients are unlikely to exercise them.

11. Staff, Faculty, Resident and Student Training and Management, Complaint Procedures, Data Safeguards, Administrative Practices

a) Staff Training and Management

* Training – The School of Dentistry will train all covered in these Privacy Policies & Procedures, as necessary and appropriate for them to carry out their functions. Covered individuals are staff, faculty, students and residents that have access to patient information. We will complete this privacy training of covered individuals by this rule by April 14, 2003.

After April 14, 2003, the School of Dentistry will train each new covered individual within a reasonable time after the member starts. We will also retain each covered employee whose functions are affected either by a material change in our Privacy Policies and Procedures or in the employee’s job functions, within a reasonable time after the change.

Form 7, Staff Review of Policies and Procedures, can be used to have covered employees acknowledge they have received and read a copy of these Policies and Procedures.

The individual department chairs will have responsibility for ensuring covered employees on their faculty receive training and that proper documentation is maintained for those faculty members. Managers will have responsibility for ensuring all covered staff members receive training and that proper documentation is obtained.

*Discipline and Mitigation – The School of Dentistry will develop, document, disseminate, and implement appropriate discipline policies for covered individuals who violate our Privacy Policies & Procedures, the Privacy Rules, or other applicable federal or state privacy law.

Covered individuals that 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 or dismissal.

b) Complaints – The School of Dentistry 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 covered employee or student who files a Complaint in good faith.

c) Data Safeguards – The School of Dentistry 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.

The School of Dentistry 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 – The School of Dentistry 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 the HIPAA privacy officer in consultation with the School of Dentistry administration may change these Privacy Policies & Procedures.

12. State Law Compliance

The School of Dentistry 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

The School of Dentistry 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

The School of Dentistry will designate a Privacy Officer and other responsible persons as required by the Privacy Rules.