Oral & Maxillofacial SurgeryAssociates (OMSA)


Effective June 10, 2009                                             Revised April 15, 2013


Under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) we are required to maintain the privacy and security of your protected health information and provide you with notice of our legal duties and privacy standards with respect to such protected health information.

We are required to abide by the terms of the notice currently in effect.  We reserve the right to change the terms of our notice at any time and to make the new notice provisions effective for all protected health information that we maintain.  In the event that we make a material revision to the terms of our notice, a revised notice will be made available to you within 60-days of such revision.  If you should have any questions or require further information, please contact our Privacy Office at Fort Wayne Office Phone Number 260-423-2340.

How We May Use or Disclose Your Health Information

Some of the following describes the purposes for which we are permitted or required by law to use or disclose your health information with out your consent or authorization.  If an authorization is required, the example will indicate so.  Any other uses or disclosures not listed will be made only with your written authorization and you may revoke such authorization in writing at any time.

Treatment:  We may use or disclose your health information to provide you with medical treatment, evaluation, or services to coordinate and to manage your healthcare.  For example, we will record such information gathered by us in rendering care to you and will record that information in your medical record.  The medical record we create or gather about you may be shared with other providers involved in coordination or management of your care.

Payment:  We may use or disclose your health information in order for services you receive may be billed to or collected from your insurance carrier or another third party.  For example, we may disclose appropriate information for reimbursement,collection or payment purposes to those involved with processing or coordinating payment.  We may also disclose your information for prior authorization.

Health Care Operations:  We may use or disclose your health information for OMSA health care operations.  Health care operations include, but not limited to, quality assessment and improvement activities,underwriting, premium rating, management and general administrative activities.  For example, members of our quality improvement team may use information in your health record to assess the quality of care that you receive and determine how to continually improve the quality and effectiveness of the services we provide.

Business Associates:  There may be instances where services are provided to our office through contracts with third party “business associates”.  Whenever a business associate arrangement involves the use or disclosure of your health information, we will have a written contract that requires the business associate to maintain the same high standards of safeguarding and securing your privacy that we require of our own employees and affiliates.  Examples of Business Associates are OMSA’s attorneys, consultants, collections agencies, and accreditation organizations.

Communication with Family or Friends:  OMSA, using their best judgment, may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your care or payment for your care.  OMSA may also disclose your condition to family or friends who accompany you to our offices.  OMSA may leave a message on your phone pertaining to a scheduled appointment or other health related issues.  The message will only be left at the phone number you provided us.  You may receive information by mail from our office. You may see or overhear protected health information while in our offices, but we make our best attempt to keep our patient information private and confidential as possible.

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

Coroners, Medical Examiners and Funeral Directors:  We may disclose health information to a coroner or medical examiner. We may also disclose medical information to funeral directors consistent with applicable law to carry out their duties.

Public Health:  As required by law, we may disclose your health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.

Breach Notification:  Under certain circumstances we may be required to notify the Indiana Attorney General and/or the Department of Health and Human Services of a breach of your patient information.  A breach occurs when there has been an unauthorized access or disclosure of your PHI and the access or disclosure poses a risk to you.  You would also receive notification of this breach by mail.

Workers’ Compensation:  We may disclose health information to the extent authorized by and to the extent necessary to comply with laws relating to workers compensation or other similar programs established by law.

To Avert a Serious Threat to Health or Safety:  Consistent with applicable federal and state laws, we may use and disclose health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.  Disclosure of this nature would only be made to an appropriate agency or individual.  In limited circumstances OMSA has a duty to warn.

Military and Veterans:  If you are a member of the armed forces, we may disclose health information about you as required by military command or with authorization. We may also release medical information about foreign military personnel as appropriate to foreign military authorities as required by law or with authorization.

Health Oversight Activities:  We may disclose health information to a health oversight agency for activities authorized by law, including audits, investigations, inspections, and licensure.

Protective Services for the President, National Security and Intelligence Activities:  We may disclose health information about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations, or for intelligence, counterintelligence, and other national security activities authorized by law or with your authorization.

Law Enforcement:  We may disclose health information when requested by a law enforcement official as part of law enforcement activities; investigations of criminal conduct; in response to court orders; in emergency circumstances; or when required to do so by law. We are required to report certain types of injuries or wounds such as gun shoot wounds and some burns. We may also release information to law enforcement to locate or identify a suspect, fugitive, material witness or missing person.  Under certain circumstances we may release information to law enforcement if you are the victim of a crime or of criminal activity at our facility.

Lawsuits/disputes:  If you are involved in a lawsuit, we may release medical information that is court ordered, administrative ordered, grand jury subpoena’s or with your authorization.

Inmates:  We may disclose health information about an inmate of a correctional institution or under the custody of a law enforcement official to the correctional institution or law enforcement official as required by law or with your authorization.

Marketing/Fund-raising:  Marketing without your authorization is prohibited unless the information is about a service or product we offer and that we receive no compensation for the marketing of such said product or service.  Occasionally OMSA may use limited information (name, address and dates of service) to let you know about fund-raising events or other charitable events.  Fundraising notification will give you the option to opt out of further notifications.

Sale of PHI:  We are prohibited from selling your protected health information without your authorization unless the sale is in conjunction with the sale of our practice.

Your Rights Regarding Your Health Information

The following describes your rights regarding the health information we maintain about you.  To exercise your rights, you must submit your request in writing to our Privacy Officer 4606-D E. State Blvd., Fort Wayne, IN 46804.

Right of Notice of Privacy.  You have the right to obtain a paper copy of this Notice of Privacy Practices at any time.  You have the right to a full 7 page notice or you may go to www.omsafw.com for an electronic version of the full Notice of Privacy Practices.

Right to Request Restrictions.  You have the right to request that we restrict uses or disclosures of your health information we disclose about you.  You may request a restriction on services you pay for out of your own pocket (not paid by insurance) that we would otherwise disclose to your insurance company for payment.  We have the right to deny certain requests for restrictions. Requests for restrictions must be made in writing to our Privacy Officer and must list what information you want restricted, whether you are requesting limits on our access or disclosure of the information and to whom you want the restrictions to apply.  For example if you restrict disclosures to a spouse or other family member.

Right to Receive Confidential Communications. You have the right to request that we send communications that contain your health information by alternative means or to alternative locations.  We must accommodate your request if it is reasonable.  For example you may request we only contact you at work.  This request must be made in writing to our Privacy Officer.

Right to Inspect and Copy.  You have the right to inspect and receive a copy of health information that we maintain about you.  If copies are requested or you agree to a summary or explanation of such information, we may charge a reasonable, cost-based fee for the costs of copying, including labor and supply cost of copying; postage; and preparation cost of an explanation or summary, if such is requested. For electronic medical records you may request an electronic version of your records at a reasonable cost for copying.  We may deny your request to inspect and copy in certain circumstances as defined bylaw. If you are denied access to your health information, you may request that the denial be reviewed.  All requests for access must be made in writing to our Privacy Officer.

Right to Amend. You have the right to request an amendment to your health information as long as we originated and maintained such information.  Your written request must include the reason or reasons that support your request.  We may deny your request for an amendment if we determine that the record that is the subject to the request was not created by us, is not available for inspection as specified by law, or is accurate and complete.  All requests for amendments must be made in writing to our Privacy Officer.

Right to Receive an Accounting of Disclosures. You have the right to receive an accounting of disclosures of your health information made by us in the six years prior to the date the accounting is requested (or shorter period as requested). This does not include disclosures made to carryout treatment, payment and health care operations; disclosures made to you;communications with family and friends you authorized; for national security or intelligence purposes; to correctional institutions or law enforcement officials; or disclosures made prior to the HIPAA compliance date of April 14,2003.  Your first request for accounting in any 12-month period shall be provided without charge.  A reasonable, cost-based fee shall be imposed for each subsequent request for accounting within the same 12-month period.  Your request for an accounting of disclosures must be made in writing to our Privacy Officer.

Right to a Breach Notification.  If an unauthorized breach occurs where your healthcare information is involved, we may be obligated to send you a notification of that breach.  A risk assessment will be conducted to ensure that the potential risk to you by the breach was investigated and mitigated to the fullest extent possible.  In addition to notifying you, if harm is indicated, we may also have to notify the Indiana Attorney General and the Department of Health and Human Services.

How to File a Complaint if You Believe Your Privacy Rights Have Been Violated

If you believe that your privacy rights have been violated, please submit your complaint in writing to:

Oral& Maxillofacial Surgery Associates
Attn: Privacy Officer
4606-D E. State Blvd.

Fort Wayne, IN 46804

You may also file a complaint with the Office of Civil Rights or the Department of Health and Human Services.  You will not be retaliated against for filing a complaint.