Notice of Privacy Practices for Protected Health Information
This notice describes how medical information about you may be used and disclosed
and how you can get access to this information. Please review it carefully!
With your consent, the practice is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.
• Example of uses of your health information for treatment purposes: A nurse obtains treatment information about you and records it in a health record. During the course of your treatment, the doctor determines a need to consult with another specialist in the area. The doctor will share the information with such specialist and obtain input.
• Example of use of your health information for payment purposes: We submit a request for payment to your health insurance company. The health insurance company requests information from us regarding medical care given. We will provide such information.
• Example of Use of Your Information for Health Care Operations: We obtain services from our insurers or other business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such insurers or other business associates as necessary to obtain these services.
Your Health Information Rights
The health record we maintain, and billing records are the physical property of the practice. The information in it, however, belongs to you. You have a right to:
• Request a restriction on certain uses and disclosures of your health information by delivering the
request in writing to our office. We are not required to grant the request, but we will comply with any
• Request a restriction on disclosures of medical information to a health plan for purposes of carrying
out payment or health care operations; and the PHI pertains solely to a health care service for which
the provider has been paid out of pocket in full-we must comply with this request;
• Request that you be allowed to inspect and copy your health record and billing record-you may
exercise this right by delivering the request in writing to our office;
• Appeal a denial of access to your protected health information except in certain circumstances;
• Request that your health care record be amended to correct incomplete or incorrect information by
delivering a written request to our office; ied, and require that the request for
amendment and any denial be attached in all future disclosures of your protected health information;
• Obtain an accounting of disclosures
• File a statement of disagreement if your amendment is denof your health information as required to be maintained by law
by delivering a written request to our office. An accounting will not include internal uses of
information for treatment, payment, or operations, disclosures made to you or made at your request,
or disclosures made to family members or friends in the course of providing care;
• Request that communication of your health information be made by alterative means or at an
alternative location by delivering the request in writing to our office; and,
• Elect to opt out of receiving further marketing communications from our office,
Revoke authorizations that you made previously to use or disclose information except to the extent
information or action has already been taken by delivering a written revocation to our office.
If you want to exercise any of the above rights, please contact the Compliance Officer in person or in writing, during normal hours. She will provide you with assistance on the steps to take to exercise your rights.
The practice is required to:
• Maintain the privacy of your health information as required by law;
• Provide you with a notice of our duties and privacy practices as to the information we collect and
maintain about you;
• Abide by the terms of this Notice;
• Notify you if we cannot accommodate a requested restriction or request; and
• Accommodate your reasonable requests regarding methods to communicate health information with
We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice.
You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our “Notice” or by visiting our office and picking up a copy.
Please turn the page over for additional information.
To Request Information or File a Complaint
If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact our Compliance Officer. Additionally, if you believe your privacy rights have been violated, you may file a written complaint to our Compliance Officer. You may also file a complaint with the US Department of Health and Human Services (“HHS”) (http://www.hhs.gov/ocr/privacy/hip aa/complaints/index.html). We cannot, and will not, require you to waive the right to file a complaint with the HHS as a condition of receiving treatment from the practice. We cannot, and will not, retaliate against you for filing a complaint with the HHS.
Other Disclosures and Uses
Notification – Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.
Communication with Family – Using our best judgment, we 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 in payment for such care if you do not object or in an emergency.
Food and Drug Administration (FDA) We may disclose to the FDA your protected health information relating to adverse events with respect to products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.
Workers Compensation – If you are seeking compensation through Workers Compensation, we may disclose your protected. health information to the extent necessary to comply with laws relating to Workers Compensation.
Public Health – As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability.
Abuse & Neglect – We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.
Correctional Institutions – If you are an inmate of a correctional institution, we may disclose to the institution, or its agents, your protected health information necessary for your health and the health and safety of other individuals.
Law Enforcement – We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement.
Health Oversight – Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.
Judicial/Administrative Proceedings We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order.
Other Uses Other uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law. or with your written authorization and you may revoke the authorization as previously provided.
Website If we maintain a website that provides information about our entity, this Notice will be on the website.
Privacy Officer: Address: Telephone: Fax E-mail: