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HIPAA Notice of Privacy Practices 

Effective Date: Jan 1, 2014 


If you have any questions about this notice, please contact the office of Dr. Paul A. Mevoli,  DMD and Dr. Wade W. Hancock, D.M.D. Tel No. 727-541-5606. 


We are required by law to: 

Maintain the privacy of protected health information 

Give you this notice of our legal duties and privacy practices regarding health  information about you 

Follow the terms of our notice that is currently in effect 


The following describes the ways we may use and disclose health information that identifies  you ("Health Information"). Except for the purposes described below, we will use and disclose  Health Information only with your written permission. You may revoke such permission at any  time by writing to our practice Privacy Officer. 

For Treatment.
We may use and disclose Health Information for your treatment and to  provide you with treatment-related health care services. For example, we may disclose Health  Information to doctors, nurses, technicians, or other personnel, including people outside our  office, who are involved in your medical care and need the information to provide you with  medical care. 

For Payment.
We may use and disclose Health Information so that we or others may bill and  receive payment from you, an insurance company or a third party for the treatment and  services you received. For example, we may give your health plan information about you so  that they will pay for your treatment. 

For Health Care Operations.
We may use and disclose Health Information for health care  operations purposes. These uses and disclosures are necessary to make sure that all of our  patients receive quality care and to operate and manage our office. For example, we may  use and disclose information to make sure the obstetrical or gynecological care you receive  is of the highest quality. We also may share information with other entities that have a relationship with you (for example, your health plan) for their  health care operation activities.

Appointment Reminders, Treatment Alternatives and Health Related Benefits and  Services.
We may use and disclose Health Information to contact you to remind you that you  have an appointment with us. We also may use and disclose Health Information to tell you  about treatment alternatives or health-related benefits and services that may be of interest to  you. 

Individuals Involved in Your Care or Payment for Your Care.
When appropriate, we may  share Health Information with a person who is involved in your medical care or payment for  your care, such as your family or a close friend. We also may notify your family about your  location or general condition or disclose such information to an entity assisting in a disaster  relief effort. 

Under certain circumstances, we may use and disclose Health Information for  research. For example, a research project may involve comparing the health of patients who  received one treatment to those who received another, for the same condition. Before we use  or disclose Health Information for research, the project will go through a special approval  process. Even without special approval, we may permit researchers to look at records to help  them identify patients who may be included in their research project or for other similar  purposes, as long as they do not remove or take a copy of any Health Information. 


As Required by Law.
We will disclose Health Information when required to do so by  international, federal, state or local law. 

To Avert a Serious Threat to Health or Safety.
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. Disclosures, however, will be made only to someone who  may be able to help prevent the threat. 

Business Associates.
We may disclose Health Information to our business associates that  perform functions on our behalf or provide us with services if the information is necessary for  such functions or services. For example, we may use another company to perform billing  services on our behalf. All of our business associates are obligated to protect the privacy of  your information and are not allowed to use or disclose any information other than as specified  in our contract. 

Organ and Tissue Donation.
If you are an organ donor, we may use or release Health  Information to organizations that handle organ procurement or other entities engaged in  procurement, banking or transportation of organs, eyes or tissues to facilitate organ, eye or  tissue donation and transplantation.

Military and Veterans.
If you are a member of the armed forces, we may release Health  Information as required by military command authorities. We also may release Health  Information to the appropriate foreign military authority if you are a member of a foreign  military. 

Workers' Compensation.
We may release Health Information for workers' compensation or  similar programs. These programs provide benefits for work-related injuries or illness. 

Public Health Risks.
We may disclose Health Information for public health activities. These  activities generally include disclosures to prevent or control disease, injury or disability; report  births and deaths; report child abuse or neglect; report reactions to medications or problems  with products; notify people of recalls of products they may be using; a person who may have  been exposed to a disease or may be at risk for contracting or spreading a disease or  condition; and the appropriate government authority if we believe a patient has been the  victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree  or when required or authorized by law. 

Health Oversight Activities.
We may disclose Health Information to a health oversight  agency for activities authorized by law. These oversight activities include, for example, audits,  investigations, inspections, and licensure. These activities are necessary for the government  to monitor the health care system, government programs, and compliance with civil rights  laws. 

Data Breach Notification Purposes. We may use or disclose your Protected Health  Information to provide legally required notices of unauthorized access to or disclosure of your health information. 

Lawsuits and Disputes.
If you are involved in a lawsuit or a dispute, we may disclose Health  Information in response to a court or administrative order. We also may disclose Health  Information in response to a subpoena, discovery request, or other lawful process by  someone else involved in the dispute, but only if efforts have been made to tell you about the  request or to obtain an order protecting the information requested. 

Law Enforcement.
We may release Health Information if asked by a law enforcement official  if the information is: (1) in response to a court order, subpoena, warrant, summons or similar  process; (2) limited information to identify or locate a suspect, fugitive, material witness, or  missing person; (3) about the victim of a crime even if, under certain very limited  circumstances, we are unable to obtain the person's agreement; (4) about a death we believe  may be the result of criminal conduct; (5) about criminal conduct on our premises; and (6) in  an emergency to report a crime, the location of the crime or victims, or the identity, description  or location of the person who committed the crime. 

Coroners, Medical Examiners and Funeral Directors.
We may release Health Information  to a coroner or medical examiner. This may be necessary, for example, to identify a deceased  person or determine the cause of death. We also may release Health Information to funeral  directors as necessary for their duties.

National Security and Intelligence Activities.
We may release Health information to  authorized federal officials for intelligence, counter - intelligence, and other national security activities authorized by law. Protective Services for the President and Others. We may disclose Health Information to  authorized federal officials so they may provide protection to the President1 other authori1z.e d  persons or foreign heads of state or to conduct ·special investigations. 

Inmates or Individuals in Custody.
If you are an Inmate of a correctional institution or under the  custody of a law enforcement official, we may release Health Information to the correctional  institution or law enforcement, official 1. This release would be if necessary: (1) for the institution  to provide you with health care; (2) to protect your health and safety or the health and safety of  others; or (3) the safety and security of the correctional institution. 


Individuals involved in Your Ca-re or Payment for Your Care.
Unless you object, we may  disclose to a member of your family, a relative, a. close friend or any other person you identify, your Protected Health lnformati1on that directly relates to that person's involvement in your health care., If you are unable to, agree or object to such a disclosure, we may disclose such information  as necessary if we determine that it is in your best interest based on our professional judgment. 

Disaster Relief.
We may disclose your Protected Health information to disaster relief organizations that seek your Protected Health Information to coordinate your care or notify family and friends of your location or condition in a disaster. We will provide you with an opportunity to  agree or object to such a di1sclosure whenever we practically can do so. 


The following uses and disclosures of your Protected Health information will be made only with  your written authorization: 

1. Uses and disclosures of Protected Health lnformation for marketing purposes: and
2. Disclosures that constitute a sale of your Protected Health Information 

Other uses and disclosures of Protected Health lnformation not covered by this notice or the laws  that apply to us win be made only with your written authorization. If you do give us an  authorization, you may revoke it at any time by submitting a written revocation to our Privacy  Officer and we will no longer disclose Protected Health information under the authorization. But  disclosure that we made in reliance on your authorization before you revoked it will not be affected  by the revocation.


You have the following rights regarding Health Information we have about you: 

Right to Inspect and Copy.
You have a right to inspect and copy Health Information that  may be used to make decisions about your care or payment for your care. This includes  medical and billing records, other than psychotherapy notes. To inspect and copy this Health  Information, you must make your request, in writing, to the office of Dr. Paul A. Mevoli, DMD  and Dr. Wade W. Hancock, D.M.D. We have up to 30 days to make your Protected Health  Information available to you and we may charge you a reasonable fee for the costs of copying,  mailing or other supplies associated with your request. We may not charge you a fee if you  need the information for a claim for benefits under the Social Security Act or any other state  of federal needs based benefit program. We may deny your request in certain limited  circumstances. If we do deny your request, you have the right to have the denial reviewed by  a licensed healthcare professional who was not directly involved in the denial of your request,  and we will comply with the outcome of the review. 

Right to an Electronic Copy of Electronic Medical Records.
If your Protected Health  Information is maintained in an electronic format (known as an electronic medical record or  an electronic health record), you have the right to request that an electronic copy of your  record be given to you or transmitted to another individual or entity. We will make every effort  to provide access to your Protected Health Information in the form or format you request if it  is readily producible in such form or format. If the Protected Health Information is not readily  producible in the form or format you request your record will be provided in either our standard  electronic format or if you do not want this form or format, a readable hard copy form. We  may charge you a reasonable, cost-based fee for the labor associated with transmitting the  electronic medical record. 

Right to Get Notice of a Breach.
You have the right to be notified upon a breach of any of  your unsecured Protected Health Information. 

Right to Amend.
If you feel that Health Information we have is incorrect or incomplete, you  may ask us to amend the information. You have the right to request an amendment for as  long as the information is kept by or for our office. To request an amendment, you must make your request, in writing, the office of Dr. Paul A. Mevoli, DMD and Dr. Wade W.  Hancock, D.M.D. 

Right to an Accounting of Disclosures.
You have the right to request a list of certain  disclosures we made of Health Information for purposes other than treatment, payment and  health care operations or for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to the office of Dr. Paul  A. Mevoli, DMD and Dr. Wade W. Hancock, D.M.D. 

Right to Request Restrictions.
You have the right to request a restriction or limitation on  the Health Information we use or disclose for treatment, payment, or health care operations.  You also have the right to request a limit on the Health Information we disclose to someone  involved in your care or the payment for your care, like a family member or friend. For  example, you could ask that we not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must make  your request, in writing, to the office of Dr. Paul A. Mevoli, DMD and Dr. Wade W. Hancock,  D.M.D. We are not required to agree to your  request unless you are asking us to restrict the use and disclosure of your Protected Health  Information to a health plan for payment or health care operation purposes and such  information you wish to restrict pertains solely to a health care item or service for which you  have paid us "out-of-pocket" in full. If we agree, we will comply with your request unless the  information is needed to provide you with emergency treatment. 

If you paid out-of-pocket (or in other words, you have requested  that we not bill your health plan) in full for a specific item or service, you have the right to ask  that your Protected Health Information with respect to that item or service not be disclosed to  a health plan for purposes of payment or health care operations, and we will honor that  request. 

Right to Request Confidential Communications.
You have the right to request that we  communicate with you about medical matters in a certain way or at a certain location. For  example, you can ask that we only contact you by mail or at work. To request confidential c  om muni cations, you must make your request, in writing, to the office of Dr. Paul A. Mevoli,  DMD and Dr. Wade W. Hancock, D.M.D. Your request must specify how or where you wish  to be contacted. We will accommodate reasonable requests. 

Right to a Paper Copy of This Notice.
You have the right to a paper copy of this notice.  You may ask us to give you a copy of this notice at any time. Even if you have agreed to  receive this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a copy of this notice on our website. To obtain a paper copy of this  notice. Please ask front desk at the office of Dr. Paul A. Mevoli, DMD and Dr. Wade W.  Hancock, D.M.D. 


We reserve the right to change this notice and make the new notice apply to Health  Information we already have as well as any information we receive in the future. We will post  a copy of our current notice at our office. The notice will contain the effective date on the first  page, in the top right-hand corner. 


If you believe your privacy rights have been violated, you may file a complaint with our office  or with the Secretary of the Department of Health and Human Services. To file a complaint  with our office, contact Dr. Paul A. Mevoli, DMD and Dr. Wade W. Hancock, D.M.D. AII complaints must be made in writing. You will not be penalized for filing a complaint.

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