Ardsley Smiles Dentistry
20 Center Street
Ardsley, NY 10502
(914) 693-6990
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.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health
information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This revised Notice takes effect February 15, 2021 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. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created
or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available 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
We use and disclose health information about you for treatment, payment, and healthcare
operations. For example:
Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that
we may do so.
Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in
allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.
Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.
Required by Law: We may use or disclose your health information when we are required to do so by law.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).
PATIENT RIGHTS
Access: You have the right to look at or get copies of your health information, with limited
exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable
cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $0.15 for each page, $15.00 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee
structure.)
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.
Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.
Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.
YOUR OTHER DATA
When you visit our website, we may utilize cookies and collect information from your browser, including but not limited to, your IP address. We do this to better understand the efficacy of our marketing efforts, who is using our website, and the geographic spread of our potential patients. This data is only used and shared internally, by us and by our marketing vendor(s). We will never sell your data to third-parties.
Consumer information will not be sold or shared with third parties for marketing purposes.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon
request.
We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human
Services.
Contact Officer: Dr. Josie Park
Telephone: (914) 693-6990
E-mail: [email protected]
Address: 20 Center Street, Ardsley, NY 10502
© 2002 American Dental Association All Rights Reserved
Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.
This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).
Ardsley Smiles Dentistry
20 Center Street
Ardsley, NY 10502
(914) 693-6990
NOTICE OF DISABILITY POLICY
Our practice is committed to making quality orthodontic care available to all patients, and to provide accommodations for disabilities whenever reasonably possible. We have also made efforts to enhance the accessibility of our website to remove barriers of communication and information access for disabled patients, parents, and guardians.
If you use assistive technology (such as a Braille reader, a screen reader, or TTY) and the format of any material on this Web site interferes with your ability to access information, please contact our Office Manager at 914-693-6990 To enable us to respond in a manner most helpful to you, please indicate the nature of your accessibility problem, the preferred format in which to receive the material, the Web address of the requested material, and your contact information. Users who need accessibility assistance can also contact us by phone through the New York Information Relay Service at 711 for TTY/Voice communication.
Accessibility Design Guidelines
Our website has been designed with the following accessibility guidelines in mind:
- The standard font used throughout the site has been chosen to be easily legible.
- Wherever possible, we use live text instead of graphics to reduce the download time of pages and increase your control.
- Our pages are designed to display without horizontal scrollbars when they are viewed at a screen resolution of 1024×768 pixels.
- No information is exclusively conveyed using color. This doesn’t mean that colors are not used to organize information; instead, it means there are also other, non-color-dependent ways of doing this.
- All images and hyperlinks, where appropriate, have an alternative text attribute. This means when an image or hyperlink is conveying important information its content is described with an alternative text.
- We have attempted specifically to comply with Section 508 referring to website accessibility standards.
- If you have difficulty accessing the site or have any comments or feedback, please do not hesitate to contact our Office Manager at 914-693-6990
Notice Under the Americans with Disabilities Act
The Practice will not discriminate against qualified individuals with disabilities on the basis of disability in the Practice’s provision of orthodontist treatment.
The Practice does not discriminate on the basis of disability in its hiring or employment practices and complies with all regulations promulgated by the U.S. Equal Employment Opportunity Commission under Title I of the Americans with Disabilities Act (ADA).
Effective Communication: The Practice will generally, upon request, provide appropriate aids and services leading to effective communication for qualified persons with disabilities so they can participate equally in the Practice’s treatment services, including qualified sign language interpreters, documents in Braille, and other ways of making information and communications accessible to people who have speech, hearing, or vision impairments.
Modifications to Policies and Procedures: The Practice will make all reasonable modifications to policies and programs to ensure that people with disabilities have an equal opportunity to enjoy all Practice programs, services, and activities. For example, individuals with service animals are welcomed in Practice offices and facilities, even though pets are generally prohibited.
Anyone who requires an auxiliary aid or service for effective communication, or a modification of policies or procedures to participate in a Practice program, service, or activity, should contact the Office Manager/ADA Coordinator at (914) 693-6990 as soon as possible, but no later than 48 hours before your appointment or a scheduled event.
The ADA does not require the Practice to take any action that would fundamentally alter the nature of its programs or services, or impose an undue financial or administrative burden.
Complaints that a Practice program, service, or activity is not accessible to persons with disabilities should be directed to:
Office Manager // Ardsley Smiles Dentistry
20 Center Street
Ardsley, NY 10502
(914) 693-6990
Or via email to [email protected]
New York Relay Services: Dial 711
The Practice will not place a surcharge on a particular individual with a disability or any group of individuals with disabilities to cover the cost of providing auxiliary aids/services or reasonable policy modifications.
