Patient’s Bill of Rights

Purpose:

Mark L. Civin, D.D.S., P.A. is committed to conducting business in compliance with all applicable laws, regulations and policies. This Policy covers the procedures the organization and workforce members must use in accommodating patient rights.

Policy:

Mark L. Civin, D.D.S., P.A. will provide meaningful processes for the accommodation of individual rights.

Procedure:

  1. Right to access protected health information (PHI)
    1. Upon receipt of a written request, Mark L. Civin, D.D.S., P.A. will send an acknowledgment to the patient/personal representative confirming receipt of the request for access.
    2. When a patient makes a written request for access, the Privacy Officer or designee will inform the patient within 30 days whether access will be granted or denied.
      1. Access must be provided within the 30 days unless an extension is necessary and the patient is notified of the extension.
      2. If the request is granted, the patient will be provided a date and time to review or pick up copies of the information.
  • If the request for access is denied, a written denial will be sent to the patient stating:
    1. The grounds for denial
    2. Whether the denial is subject to review
    3. How the patient may have the denial reviewed
    4. How to file a complaint with the Privacy Officer or Office for Civil Rights
  1. Providing access
    1. Upon receipt of the request, and unless the request is appropriately denied, Mark L. Civin, D.D.S., P.A. will provide the patient/personal representative with access to and a copy of his/her designated record set.
    2. The patient may request, and Mark L. Civin, D.D.S., P.A. will provide, the information in an electronic format, provided such format is available.
  • If electronic format is not available, Mark L. Civin, D.D.S., P.A. will provide an alternate, readable format to the patient.
  1. If the patient provides portable media (disc, flash drive, etc.) to download records, and the media presents a reasonable security risk, it need not be utilized.
  2. The patient may be offered, but is not compelled to purchase, portable media from Mark L. Civin, D.D.S., P.A..
  3. When the records are maintained in paper, or mixed media, Mark L. Civin, D.D.S., P.A. is not obligated to scan the records to provide an electronic copy.
  • The patient may request that the electronic record be transmitted to a third party.
  • If the patient requests transmittal by email, the transmission need not be encrypted, provided the patient is notified of and accepts the risks of unencrypted email. A reasonable, cost- based fee only includes:
    1. The labor cost for copying in paper or electronic format
    2. Supplies for creating a paper copy or electronic portable media (if requested by the patient)
    3. Postage
    4. Costs of preparing a summary, if requested
    5. No retrieval or standard fee will be charged
  1. Denial of access
    1. Mark L. Civin, D.D.S., P.A. may deny a request for access when:
      1. The patient/personal representative requests access to psychotherapy notes
      2. The requested information is compiled for use in legal or regulatory proceedings
      3. The requested information is not in the designated record set
      4. The request concerns treatment as part of a research protocol
      5. The information is subject to and may be denied under the federal Privacy Act
      6. The person requesting the information is an inmate and the correctional facility certifies the inmate should be denied access
      7. The requested information was obtained from someone who is not a health care provider under a promise of confidentiality
    2. A denial of access based upon one of these conditions is not subject to review
  • Mark L. Civin, D.D.S., P.A. may deny a request for access when:
    1. Mark L. Civin, D.D.S., P.A. believes that access is likely to endanger the life or physical safety of the patient or another person
    2. The records reference another person and access may cause substantial harm to that person
    3. The request for access is made by a personal representative and access is likely to cause harm to the patient or another person
  1. When Mark L. Civin, D.D.S., P.A. denies access on one of these grounds, the denial is subject to review.
  2. When the denial is subject to review, the notification will include a statement that:
    1. The patient may have the decision reviewed by notifying Mark L. Civin, D.D.S., P.A. within 30 days in writing that he/she wants the decision reviewed
    2. The decision will be reviewed by a health care professional who was not involved in the initial denial decision
    3. Mark L. Civin, D.D.S., P.A. will designate the reviewing professional
    4. The reviewing professional’s decision will be a final decision
    5. The patient shall use the Request for Review of Denial of Access Form to request review.
  3. Upon receipt of a request for review of denial, Mark L. Civin, D.D.S., P.A. will send the patient a Letter Acknowledging Receipt of Request for Review of Denial.
  • Within 30 days of a request for review, Mark L. Civin, D.D.S., P.A. will appoint a Review Officer.
  • The Review Officer will determine if there were sufficient grounds to deny access, or will permit access.
  1. The Review Officer’s decision will be communicated, in writing, to the patient.
  1. Copies of all communications related to request for access will be maintained in the designated record set.
  1. Right to an accounting of disclosures
    1. Upon receipt of a written request for accounting, Mark L. Civin, D.D.S., P.A. will send the patient/personal representative a written acknowledgement confirming receipt of the request.
    2. Within 30 days after receipt of a written request for an accounting of disclosures, Mark L. Civin, D.D.S., P.A. will provide an accounting of all disclosures made by it or its business associates.
      1. Exclusions include:
        1. For treatment, payment, or health care operations
        2. To the individual or the individual’s personal representative
        3. Pursuant to an authorization
        4. Of a limited data set
        5. For national security or intelligence purposes
        6. To correctional institutions or law enforcement officials for certain purposes regarding inmates or individuals in lawful custody
        7. Incident to otherwise permitted or required uses or disclosures
      2. Accounting of disclosures to health oversight agencies and law enforcement officials must be temporarily suspended on their written representation that an accounting would likely impede their activities.
  • If a law enforcement officer provides a written statement that providing the accounting would impede the law enforcement agency’s activities and specifies a time period to delay the accounting, Mark L. Civin, D.D.S., P.A. will not provide the accounting during that time period.
  1. If a law enforcement officer makes a verbal request to delay an accounting, Mark L. Civin, D.D.S., P.A. will document the request and the name of the law enforcement official making the request and will not provide the accounting for a period of 30 days.
  2. If the request only encompasses specific disclosures, then the disclosures that are not subject to the request will be provided.
  3. At the end of the delay period, Mark L. Civin, D.D.S., P.A. will provide the patient/personal representative with the remainder of the accounting.
  1. The accounting will encompass the six-year period prior to the request unless otherwise limited by the requestor.
  2. The accounting document must be provided in the form or format requested by the patient/personal representative, if it is readily producible in the requested format.
    1. If the form or format is not readily producible, then the accounting will be provided by a hard copy.
    2. The accounting document will include:
      1. The date of the disclosure, a period of time when the disclosure occurred (a month and year), or for multiple disclosures for the same purpose, the date of the first disclosure and last disclosure may be provided
      2. The name of the recipient (if providing the recipient’s name would disclose PHI of the recipient, the term “person, patient, enrollee” may be used)
      3. The address of the recipient
      4. A brief description of the information disclosed
      5. A brief description of the purpose of the disclosure.
    3. Mark L. Civin, D.D.S., P.A. will document and retain said documentation of the accounting of disclosures for at least six years from the date of the accounting.
      1. Documentation will include the written accounting that is provided to the person and the titles of persons responsible for receiving and processing requests for accountings.
    4. Mark L. Civin, D.D.S., P.A. will provide the first request for an accounting in any one year free of charge and will impose a reasonable, cost-based fee for additional accountings within a 12-month period.
      1. Mark L. Civin, D.D.S., P.A. will inform the patient/personal representative of the fee prior to providing the accounting.
    5. Right to amend health
      1. Mark L. Civin, D.D.S., P.A. will amend PHI contained in a designated record set when a patient makes a written request describing:
        1. The content of the requested amendment
        2. The reason for the requested amendment
  • The place in the records where the amendment should be placed
  1. Mark L. Civin, D.D.S., P.A. will not amend a designated record set when it is determined:
    1. Mark L. Civin, D.D.S., P.A. did not create the information to be amended
    2. The information to be amended is not part of the designated record set
  • The information in the designated record set was accurate and correct when it was created
  1. The information to be amended is information that the patient would not be entitled to access.
  1. If more information is necessary to determine whether the request for amendment should be granted, the patient may be contacted for additional information.
  2. Mark L. Civin, D.D.S., P.A. will notify the patient in writing within 60 days of the date of the request that the amendment will or will not be made.
  3. If additional time is needed to make the determination of whether the information should be amended, Mark L. Civin, D.D.S., P.A. will notify the patient of the delay and provide an estimated date when the decision to amend or deny amendment will be provided.
  4. If the health record will be amended, Mark L. Civin, D.D.S., P.A. will make reasonable efforts to inform and provide the amendment to persons identified by the patient.
    1. Mark L. Civin, D.D.S., P.A. will also send amendments to persons who have previously received the patient’s information and who may have relied upon the health information being correct.
  5. If the request for amendment is denied, the patient will be informed in writing of the reason for the denial.
    1. The patient will be informed of:
      1. His/her right to submit a written statement of disagreement
      2. The process by which a statement of disagreement is submitted
      3. Notice that if he/she does not wish to submit a disagreement statement that the request for amendment and the denial will be included in all future disclosures
      4. A description of how he/she can file a complaint with the Privacy Officer or the Office for Civil Rights.
    2. If a disagreement statement is submitted, Mark L. Civin, D.D.S., P.A. may prepare a written rebuttal.
      1. The disagreement statement and the rebuttal statement will be included in the patient’s designated record set.
      2. The patient will be given a copy of the rebuttal statement.
    3. If only part of the requested amendment is made, the patient will be notified, in writing, that the amendment will be made in part and specifying the parts of the requested amendment that will be made.
      1. The patient will be informed of
        1. The reason for the denial of the remaining parts of the requested amendment
        2. His/her right to submit a written statement of disagreement
        3. The process by which a statement of disagreement is submitted
        4. Notice that if he/she does not wish to submit a disagreement statement that the request for amendment and the denial will be included in all future disclosures
        5. A description of how he/she can file a complaint with the Privacy Officer or the Office for Civil Rights.
      2. If a disagreement statement is submitted, Mark L. Civin, D.D.S., P.A. may prepare a written rebuttal.
  • The disagreement statement and the rebuttal statement will be included in the patient’s designated record set.
  1. The patient will be given a copy of the rebuttal statement.
  1. All subsequent disclosures of the patient’s PHI will include the amendment, if granted.
  1. Right to a communication accommodation
    1. When Mark L. Civin, D.D.S., P.A. receives a written request from a patient to communicate with him/her in a specific manner or at a specific location Mark L. Civin, D.D.S., P.A. will evaluate the request to ascertain whether it is reasonable.
    2. Mark L. Civin, D.D.S., P.A. will notify the patient in writing, within 30 days, whether the request will be granted.
    3. Mark L. Civin, D.D.S., P.A. will not inquire into the reason for the request, but may contact the patient to obtain clarifying information about the request.
    4. If the request is denied, Mark L. Civin, D.D.S., P.A. will notify the patient that the request has been denied and that the patient has a right to complain to the Privacy Officer or the Office for Civil Rights.
    5. If the request is granted, Mark L. Civin, D.D.S., P.A. will communicate the information to the necessary individuals and departments to facilitate the accommodation.
    6. Mark L. Civin, D.D.S., P.A. will accommodate requests that a communication be sent to an alternate location when the failure to do so would endanger the patient.
  2. Right to a restriction of disclosures
    1. Patients requesting restrictions on the disclosures of PHI will complete the Request to Restrict Uses and Disclosures of Protected Health Information Form.
    2. Mark L. Civin, D.D.S., P.A. must agree to restrict disclosures to a third party payer when the patient requests the restriction and the disclosure pertains solely to a health care item or service for which the patient or responsible party has paid in full.
      1. The person to whom the request is made must immediately notify the Privacy Officer of the request.
      2. The Privacy Officer or designee will notify the billing or other appropriate office of the restriction request.
  • The patient’s health record will be marked to indicate that the restriction is in place.
  1. Mark L. Civin, D.D.S., P.A. will not terminate a restriction for disclosures to a third party payer for a self-paid item or service unless requested by the patient or the patient fails to make payment for the health care item or service.
  2. To avoid situations where patients later fail to make payment, Mark L. Civin, D.D.S., P.A. will use best efforts to collect payment in full at the time of the request for restriction.
  3. If payment in full is not collected at the time of the request, and the patient later fails to make payment, Mark L. Civin, D.D.S., P.A. will make reasonable efforts to collect the payment from the patient or responsible party before billing the patient’s third party payer.
  1. Mark L. Civin, D.D.S., P.A. has the discretion to agree to restrict disclosures for:
    1. Treatment, payment, or health care operations
    2. Disclosures to individuals involved in the patient’s health care
  • Disclosures for notification and disaster relief services at the patient’s request
  1. The request must be made in writing to the Privacy Officer.
  2. The patient will be notified, in writing, within 30 days if his/her request is granted or denied.
    1. If denied, the notification will also inform the patient that he/she has the right to file a Complaint with the Privacy Officer or the Office for Civil Rights.
  3. When the patient requests a restriction be sent to an alternative location because the failure to do so would endanger the patient, Mark L. Civin, D.D.S., P.A. will accommodate those requests.
  4. When a request for a restriction is granted, the appropriate departments must be notified so the information is not disclosed, and the designated record set and billing information noted so the information is not disclosed.
    1. Except for a requested restriction to a health plan for a self-paid item, service, or treatment, the Privacy Officer may terminate a restriction at any time upon written notification to the patient.
  5. If the restricted information is necessary to provide emergency treatment, it may be disclosed.
  1. Right to file a complaint
    1. Mark L. Civin, D.D.S., P.A. will inform patients that they have a right to file a Complaint with the Privacy Officer and the Office for Civil Rights.
    2. Upon receipt of a Complaint, the Privacy Officer will inform the patient within 30 days in writing that the Complaint has been received and will be processed.
    3. The Privacy Officer will investigate all written privacy complaints and determine whether there was a violation of the privacy standards.
    4. If a member of the workforce, medical staff, or a business associate violated the privacy standards, the Privacy Officer in conjunction with the Department of Human Resources, the Medical Staff Office, Administration, and/or other departments as deemed necessary will take appropriate action to remediate the conduct.
    5. The patient will be informed of the results of the investigation and when applicable, efforts to mitigate any harmful effects of the conduct will be made.
    6. The investigation and resolution of complaints may be combined with other quality assurance, risk management, and peer review functions.
  2. Documentation retention
    1. All documents related to the exercise of an individual right will be maintained for at least six years from the date of the final document pertinent to the requested exercise of rights. The Privacy Officer will maintain the documentation.

For any questions please contact us

Palm Beach Gardens Dentist

Mark L. Civin, D.D.S., P.A.
5600 PGA. Boulevard #102
Palm Beach Gardens, FL 33418
(561) 258-9037