Note:  Before you can complete our convenient online registration forms you'll need to read through our HIPAA privacy statement below.  It tells how we protect your personal information.  Only after clicking "I Accept" will you be able access the online forms.

 

RAY VALLECILLO, D.D.S., ALINA VALLECILLO PETERS, D.D.S.

In compliance with HIPAA (Health Insurance Portability and Accountability Act of 1996), please review the following information which explains how we protect your private dental care information. When you have reviewed this information, you will be asked to acknowledge and consent to our use and disclosure of your protected dental information for treatment and payment. If you agree to these provisions, please click “I Accept” button at the bottom of this document.

HIPAA NOTICE OF PRIVACY PRACTICES

(Effective: June 1, 2005)

THIS NOTICE DESCRIBES HOW YOUR DENTAL INFORMATION
 MAY BE USED AND DISCLOSED AND HOW YOU MAY GET
ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS
DOCUMENT CAREFULLY.

IF YOU HAVE ANY QUESTIONS ABOUT THIS HIPAA DOCUMENT PLEASE CONTACT OUR OFFICE AT (252) 728 2025 OR WRITE US AT 1621 LIVE OAK STREET, BEAUFORT, N.C. 28516

THIS DOCUMENT DESCRIBES OUR PRACTICES CONCERNING:

  • Any staff health care professional authorized to enter information into your dental file.
  • All areas, departments, and services of practice.
  • Those entities, sites, and locations that may share dental information with each other for treatment, payment, and operational purposes described in this notice.

 

REGARDING YOUR DENTAL INFORMATION

We understand that your dental information is very personal. We are committed to protecting the information you give us. We create a comprehensive, secure record of your care and the services you receive at our practice. We need these records to provide you with the upmost in quality dental care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by the doctors or staff members. This notice will tell you about the ways in which we may use and disclose your dental information. We also describe your rights and certain obligations we have regarding the use and disclosure of dental information.

THE LAW REQUIRES US TO:

  • Make sure that all dental information that identifies you is kept private.
  • Give you this notice of our legal duties and privacy practices with respect to dental information.
  • Follow the terms of this notice that is currently in effect.

 

HOW WE MAY USE AND DISCLOSE YOUR DENTAL INFORMATION:

To follow, is a list of categories which describe the different ways we may use and disclose dental information about you. There is an explanation for each category and some examples. Not every use or disclosure in a category is listed. However, all of the ways we are permitted to use and disclose your information will fall within one these categories.

FOR TREATMENT: We may use and disclose dental information about you so that we may provide you with dental treatment or services. We may disclose dental information about you to doctors, clinicians, or other staff personnel who are involved in your dental care. Different doctors or staff members may share dental information about you in order to coordinate the different things you need, such as prescriptions. We may also disclose dental information about you to people outside our office who may be involved in your dental care, such as family members or others we use to provide services that are part of your care.

FOR PAYMENT: We may use and disclose dental information about you so that the treatment and services you receive may be billed to you and payment may be collected from you, an insurance company, or a third party. For example, we may tell your dental care plan about a treatment you are going to receive or to determine whether your plan will cover the treatment.

FOR HEALTH CARE OPERATIONS: We may use and disclose dental information about you for our practice operations. These uses and disclosures are necessary to operate our dental practice and make sure that you receive quality care. For example, we may use dental information to review our treatment and services and to evaluate the performance of our staff in caring for you.

APPOINTMENT REMINDERS: We may contact you by telephone, mail, or e-mail to remind you or confirm that you have an appointment for dental care at our office.

PATIENT REQUESTED DISCLOSURES: We will release your dental or prescription information to you verbally over the telephone after you have established your identity by providing your full name, your current address, your telephone number, date of birth, and the last four digits of your social security number. We will release your protected dental information to another doctor or dental practice upon receipt of a signed release form.

TREATMENT ALTERNATIVES: We may use and disclose dental information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.

DENTAL-RELATED SERVICES AND BENEFITS: We may use and disclose your dental information to tell you about dental-related services and benefits that may be of interest to you.

PARTIES INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE: We may release dental information about you to a family member who is involved in your dental care. We may also give information to someone who may help pay for your care.

RESEARCH: Under certain circumstances, we may use and disclose dental information about you for research purposes. All research projects, however, are subject to a special approval process. We will ask for your specific permission if the researcher will have access to your name, address, or other information that reveals who your are, or will be involved in your care.

AS REQUIRED BY LAW: We will disclose dental information about you when required to do so by federal, state, or local law.

TO AVERT A SERIOUS THREAT TO HEALTH AND SAFETY: We may use and disclose dental information about you when it is necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone directly able to help prevent the threat.

SPECIAL CIRCUMSTANCES:

MILITARY AND VETERANS: If you are a member of the armed forces, we may release dental information about you as required by military command authorities.

WORKER’S COMPENSATION: We may release dental information about you for worker’s compensation or similar programs. These programs provide benefits for work-related injuries or illness.

PUBLIC HEALTH RISKS: We may disclose dental information about you for public health activities. These activities may include the following:

  • Prevention or control of disease, injury, or disability.
  • Report child abuse or neglect.
  • Report reactions to medications or problems with products.
  • Notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
  • Notify the appropriate government authorities 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: We may disclose dental information to a health oversight agency for activities authorized by law. This oversight may include, but may not be limited to 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.

DISPUTES AND LAWSUITS: If you are involved in a dispute or lawsuit, we may disclose dental information about you in response to a court or administrative order. We may also disclose dental information about you 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 dental information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons, or similar process.

YOUR RIGHTS REGARDING YOUR DENTAL INFORMATION

You have the following rights regarding dental information we maintain about you:

RIGHT TO INSPECT AND COPY: You have the right to inspect and request copies of dental information that may be used to make decisions about your dental care and medical care in general. This usually includes dental and billing records. To inspect and copy dental information from our files, you must submit your request in writing to: DENTAL RECORDS REQUEST, RAY VALLECILLO, D.D.S., P.A., 1621 LIVE OAK STREET, BEAUFORT, NORTH CAROLINA, 28516. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, shipping, or other supplies associated with your request.

RIGHT TO AMEND: If you feel that the dental information we have compiled about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment as long as the information is kept by and for the practice. To request an amendment, your request must be made in writing and submitted to: DENTAL RECORDS REQUEST, RAY VALLECILLO, D.D.S., P.A., 1621 LIVE OAK STREET, BEAUFORT, NORTH CAROLINA, 28516. In addition, you must provide a reason that supports your request. We may deny your request for an amendment if:

  • The information was not created by us, unless the person or entity that created the information is no longer available to make the amendment.
  • The information is not part of the dental information kept by or for our practice.
  • The information is not part of the information which you would be permitted to inspect and copy.
  • The information is accurate and complete.

RIGHT TO AN ACCOUNTING OF DISCLOSURES: You have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of dental information about you. To request this list you must submit your request in writing to: DENTAL RECORDS REQUEST, RAY VALLECILLO, D.D.S., P.A., 1621 LIVE OAK STREET, BEAUFORT, NORTH CAROLINA, 28516. Your request must state a time period, which may not be longer than six years. Your request should indicate in what form you want the list (paper, electronically, etc.).

RIGHT TO REQUEST RESTRICTIONS: You have the right to request a restriction or limitation on the dental information we use or disclose about you for treatment, payment, or health care. You also have the right to request a limit on the dental information we disclose about you to someone who is involved in your care or the payment for your care.

WE ARE NOT REQUIRED TO AGREE TO YOUR REQUEST: If we do agree to your request, we will not comply unless information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to: DENTAL RECORDS REQUEST, RAY VALLECILLO, D.D.S., P.A., 1621 LIVE OAK STREET, BEAUFORT, NORTH CAROLINA, 28516. In your request, you must tell us what information you want to limit; whether you want to limit our use, disclosure, or both; and to whom you want the limits to apply.

RIGHT TO REQUEST CONFIDENTIAL COMMUNICATION: You have the right to request that we communicate with you about dental information and matters in a certain way or at a certain location. For example, you may ask that we only contact you at work, at home, or by mail. To request confidential communications, you must make your request in writing to: DENTAL RECORDS REQUEST, RAY VALLECILLO, D.D.S., P.A., 1621 LIVE OAK STREET, BEAUFORT, NORTH CAROLINA, 28516. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

RIGHT TO A PAPER COPY OF THIS NOTICE: You have a right to a paper copy of this notice. You may print it from this website or ask us for a copy at any time. Even if you agree to this notice electronically, you are still entitled to a paper copy of this notice. You may obtain a paper copy of this notice by writing: DENTAL RECORDS REQUEST, RAY VALLECILLO, D.D.S., P.A., 1621 LIVE OAK STREET, BEAUFORT, NORTH CAROLINA 28516.

ELECTRONIC SECURITY

Our practice places the greatest importance on protecting your privacy. We have taken multiple website security precautions to insure protection of your private information. However, our practice cannot absolutely guarantee that any electronic communication is totally secure. Our practice will take all measures deemed necessary to secure and protect your dental information from loss, misuse, and alteration; but we cannot warrant that any dental information provided by you and conveyed electronically through this website will be protected absolutely. You always have the option of submitting information in-person to a staff member at our office.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with our practice or the Secretary of the Department of Health and Human Services. To file a complaint, submit your complaint in writing to: DENTAL RECORDS REQUEST, RAY VALLECILLO, D.D.S., P.A., 1621 LIVE OAK STREET, BEAUFORT, NORTH CAROLINA, 28516. You will not be penalized for filing a complaint.

OTHER USES OF DENTAL INFORMATION

Other uses and disclosures of dental information not covered by this notice or the laws that apply to its use will be made only with your written permission. If you provide us permission to use or disclose dental information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose dental information about you for the reasons covered by your written authorization. You understand that we are unable to recover any disclosure we have already made with your permission, and that we are required to retain our records of care that we provided to you.

CHANGES TO THIS NOTICE

We reserve the right to change or make revisions to this notice. We reserve the right to make the revised or changed notice effective for dental information we already have about you as well as any information we receive in the future. Any revisions or changes to this notice will be clearly posted in our practice reception area or at our front desk. The notice will contain, on the first page, the effective date. In addition, each time you register at our office or come in for treatment, you may request a copy of the current notice in effect.