Health Insurance Portability and Accountability Act
Statement of Privacy Practices
This statement of privacy practices describes how dental information about you may be disclosed and
how you can get access to this information. Please read carefully
Rebecca Bockow, DDS, PLLC collects and maintains a record of the health care services we
provide you. In keeping with the Health Insurance Portability and Accountability Act (HIPAA),
and the State of Washington, we are dedicated to protect your rights of privacy and the
confidential information entrusted to us.
The commitment of each employee to ensure that your health information is never
compromised is a principal concept of our practice. We will not disclose your protected
health information unless you direct or authorize us to do so or unless it is otherwise allowed or
compelled by law. We may, from time to time, amend our privacy policies and practices but
will always inform you of any changes that might affect your rights.
You may see your record or get more information about it at “Your Individual Rights about
Patient Health Information” section of the Notice. You may request to review and copy your
personal record and you may also request that we make corrections to the record.
Our Statement of Privacy Practices is currently in effect and provides information about the use
and disclosure of protected health information by Rebecca Bockow, DDS, PLLC and our
employees. It is applicable in all instances wherein individually identifiable health information is
collected from you and services are provided for you. Our Statement:
- Defines your rights and our obligations when using your health Information,
- Informs you about laws that provide special protections,
- Explains how your protected health information is used and how, under certain circumstances, it may be disclosed,
- Tells you how changes in this statement will be made available to you.
In synopsis form, you have a right to:
- Request restricted use of your health information. (Please understand that we may not agree to your request),
- Request that we not disclose to your health plan of services for which you self-pay in full,
- Request that we communicate with you by alternate methods,
- Review and receive copies of your personal health record,
- Request for amendments and/or changes be made to your record,
- Request an accounting of disclosures of your health information,
- File complaints related to failure to protect the privacy of your health information,
- Direct us not to share information with your family members,
- Request that you not be listed in/on our facility directory.
Protected Healthcare Information
It is important that you know not only that we limit requests for your personal information to that
needed to provide quality health care, implement payment activities, and conduct normal
health practice operations, but understand what “Protected Healthcare Information” is. This
may include your name, address, telephone number(s), Social Security Number, employment
data, dental history, health records, and/or any personal information that is unique to you.
While most of the information will be collected from you, we may obtain information from third
parties if it is deemed necessary. Regardless of the source, your personal information will
always be protected to the full extent of the law.
Protecting Your Personal Information
We use and disclose the information we collect from you only as allowed by the HIPAA and the
state of Washington. This includes when it is used and disclosed to perform treatment, obtain
payment, and conduct operational activities. Your personal health information will never be
otherwise given to anyone – even family members – without your written consent. You, of
course, may give written authorization for us to disclose your information to anyone you
choose, for any purpose.
Our Statement of Privacy Practices applies to all personal health information collected or
created by Rebecca Bockow, DDS, PLLC or received from outside healthcare providers. This
information may identify you, relate to your past, present or future physical or mental condition,
the care provided, or any reference to payment for your health care.
For example, protected health information includes symptoms, test results, diagnoses, health
information from other providers, as well as billing and payment information relating to these
services. This information is protected because it is often part of your health or dental record,
which we can use as:
- A method of communication among health professionals who contribute to your care,
- A legal record describing the care you received,
- A means by which you can verify that services billed were provided,
- A tool to educate health professionals,
- A source of data for dental research,
- A source of information for public health officials,
- A source of information for facility planning,
- A tool to assess and improve the care we provide,
- A method by which we can provide a better understanding of your record,
- A method by which we can ensure your record’s accuracy,
- A system to assist you to more clearly understand the circumstances and conditions in and by which others may have access to your personal information.
- A tool for us to make more informed decisions when authorizing disclosures to others.
Use and Disclosure of yoru Protected Health Information – Without your Autorhization
As stated above we may, under allowed circumstances use and disclose protected health
information (PHI) without your specific authorization. Examples of such instances are included
Treatment:We may use and disclose your PHI to provide treatment. For example, we can:
- Use your information to find out whether certain tests, therapies, and medicines should be ordered,
- Provide your information to staff members to better understand what your healthcare needs are how to evaluate your response to treatment,
- Disclose your PHI to another one of your treatment providers in order to provide you with the best possible health care.
Payment: We may use your health information for payment purposes. Such instances may
- Preparation of claims for payment of services,
- Billing your insurance directly, including information that identifies you, as well as your diagnosis, the procedures performed, and supplies used so that we can be paid for the treatment provided,
- Collection activities (if necessary) to obtain payment for services.
Health Care Operations: We may use and disclose your health information to support the
daily activities related to health care. Examples include:
- Use and disclosure to monitor and improve our health services.
- Use by authorized staff to review at portions of your record to perform administrative activities.
Train Staff and Students: We may use and disclose your information to teach and train staff
how to review patient health information.
Contact You for Information: Your PHI may also be used to contact you. In example, we may
call you or send you a letter to remind you about your appointment, provide test results, inform
you about treatment options, or advise you about other health-related benefits and services.
Business Associates: Your PHI may be used by Rebecca Bockow, DDS, PLLC and disclosed
as needed to individuals, organizations, or companies to comply with our legal obligations
described in this Notice. An example is disclosure of your PHI to consultants, attorneys, or third
parties to assist in our business activities. All such entities must sign a Business Associate Agreement to protect the confidentiality of your private information.
Additional Use and Disclosures
We also use and disclose your information to enhance health care services, protect patient
safety, safeguard public health, ensure that our facilities and staff comply with government
and accreditation standards, and when otherwise compelled or allowed by law. For example,
we provide or disclose information:
- About FDA-regulated drugs and devices to the U.S. Food and Drug Administration.
- To government oversight agencies with data for health oversight activities such as auditing or licensure.
- To public health authorities with information on communicable diseases and vital records.
- To your employer, findings relating to the evaluation of work-related illnesses or injuries.
- To workers’ compensation agencies and self-insured employers for work-related illness or injuries.
- To appropriate government agencies when we suspect abuse or neglect.
- To appropriate agencies or persons when we believe it necessary to avoid a serious threat to health or safety or to prevent serious harm.
- To organ procurement organizations to coordinate organ donation activities.
- To law enforcement when required or allowed by law, including the Office of Civil Rights to conduct OCR investigations.
- For court order or lawful subpoena.
- To coroners, medical examiners, and funeral directors.
- To government officials when required for specifically identified functions such as national security.
- When otherwise required by law, such as to the Secretary of the United States Department of Health and Human Services for purposes of determining compliance with our obligations to protect the privacy of your health information.
- If you are a member of the armed forces, we may release dental information about you as required by military command authorities. We may also release dental information about foreign military personnel to the appropriate foreign military authority.
Your Rights to Object
Disclosure to Family, Friends, or Others. You may object to our disclosing your general
health condition (“good”, “fair”, “critical”, etc.) to an individual, or individuals, you have
identified who have an active interest in your care, payment for your health care, or who may
need to notify others about your general condition, location, or death. If you do not so
indicate, we will use our best professional judgment to provide relevant protected health
information to your family member, friend, or another identified person.
Use and Disclosures Requiring your Authorization
Our offices and electronic systems are secure from unauthorized access and our employees
are trained to make certain that the confidentiality of your records is always protected. Our
confident that your protected health information will never be improperly disclosed or released.
Other than the uses and disclosures described above, we will not use or disclose your
protected health information without your written authorization. You may revoke your written
authorization, at any time unless prohibited by law, or disclosure is required for us to obtain
payment for services already provided, or we have otherwise relied on the authorization.
Additional Protection of Your Patient Health Information
Special state and federal laws apply to certain classes of patient health information. For
example, additional protections may apply to information about sexually transmitted diseases, drug and alcohol abuse treatment records, mental health records, and HIV/AIDS information. When required by law, we will obtain your authorization before releasing this type of information.
Your Individual Rights about Patient Health Information
You may contact Rebecca Bockow, DDS, PLLC to exercise your rights related to the use and
disclosure of your protected health information. You may contact us at:
Rebecca Bockow, DDS, PLLC
509 Olive Way, Suite 840
Seattle, Washington 98101
Attn: Dr. Bockow
Your specific rights are listed below and include:
- The right to request restricted use: You may request in writing that we not use or
disclose your information for treatment, payment, and/or operational activities except when
authorized by you, when required by law, or in emergency circumstances. We are not
legally required to agree to your request. If you request that we restrict the use of your
private information, we will provide you with written notice of our decision about your
- The right to request non-disclosure to health plans: You have the right to request in
writing that health care items or services for which you self-pay for in full in advance of your
visit not be disclosed to your health plan.
- The right to receive confidential communications: You have the right to request that
we communicate with you about dental matters in a particular way or at a certain location.
For example, you can ask that we only contact you at work or by mail. To request
confidential communications, you must make your request in writing to the address above.
We will grant all reasonable requests. Your request must specify how or where you wish to be
- The right to inspect and receive copies: In most cases, you have the right to inspect and receive a copy of certain health care information including certain dental and billing records. If you request a copy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request.
- The right to request an amendment to your record: If you believe that information in your record is incorrect or that important information is missing, you have the right to request in writing that we make a correction or add information. In your request for the amendment, you must give a reason for the amendment. We are not required to agree to the amendment of your record, but a copy of your request will be added to your record.
- The right to know about disclosures: You have the right to receive a list of instances in which we have disclosed your health information. Certain instances will not appear on the list, such as disclosures for treatment, payment, or health care operations or when you have authorized the use or disclosure. Your first accounting of disclosures in a calendar year is free of charge. Any additional request within the same calendar year requires a processing fee.
- The right to make complaints: If you believe that we have violated your privacy, or you disagree with a decision we made about access to your records, you may file a complaint directly to Dr. Bockow using the contact information above. Neither Dr. Bockow, nor any employee of Rebecca Bockow, DDS, PLLC will retaliate against anyone for filing a complaint.
You may also contact:
U.S. Department of Health and Human Services,
Office for Civil Rights:
2201 Sixth Avenue – Mail Stop RX-11
Seattle, WA 98121-1831
206-615-2290; 206-615-2296 (TTY)
Toll free: 1-800-362-1710; 1-800-537-7697 (TTY)
If it is found that your patient information is used or disclosed in a manner that is not consistent with the practices described in this notice, Rebecca Bockow, DDS, PLLC will fully investigate the matter to assess if there was a breach in the protection of your PHI. The assessment will be conducted to determine whether the information that was used or disclosed has significant risk of physical, financial, or reputational harm to you. If so, Rebecca Bockow, DDS, PLLC will notify you and Health and Human Services in writing.
Privacy Notice Changes
We are required by law to protect the privacy of your information, to provide this Statement of Privacy Practices and to follow the privacy practices that are described herein. We reserve the right to change the privacy practices described and the right to make the revised or changed Statement effective for protected health information we already have as well as any information we may receive in the future.
We have posted a copy of our current Statement for your review and reference. Additionally, each time you visit our office for treatment or health care services, you may request a copy of our current Statement of Privacy Practices. An electronic version of the notice is posted on our web site.