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.
If you have any
questions about this
notice, please contact
our office.
This Notice of
Privacy Practices
describes how we may use
and disclose your
protected health
information to carry out
treatment, payment or
health care operations
and for other purposes
that are permitted or
required by law. It also
describes your rights to
access and control your
protected health
information. “Protected
health information” is
information about you,
including demographic
information, that may
identify you and that
relates to your past,
present or future
physical or mental
health or condition and
related health care
services.
We are required to abide
by the terms of this
Notice of Privacy
Practices. We may change
the terms of our notice
at any time. The new
notice will be effective
for all protected health
information that we
maintain both before and
after the change. Upon
your request, we will
provide you with any
revised Notice of
Privacy Practices by
calling the office and
requesting that a
revised copy be sent to
you in the mail or
asking for one at the
time of your next
appointment.
1. Uses and
Disclosures of Protected
Health Information
You will be asked by
your physician to sign
this Notice of Privacy
Practices. We will make
a good faith effort to
obtain a written
acknowledgement that you
received this Notice of
Privacy Practices for
Protected Health
Information the first
time we provide services
to you after April 14,
2003 or as soon as
reasonably practicable
under the circumstances.
Your protected health
information may be used
and disclosed by your
physician, our office
staff and others outside
of our office that are
involved in your care
and treatment for the
purpose of providing
health care services to
you. Your protected
health information may
also be used and
disclosed to obtain
payment for your health
care bills and to
support the operation of
the physician’s
practice.
Following are
examples of the types of
uses and disclosures of
your protected health
care information that
the physicians office is
permitted to make. These
examples are not meant
to be exhaustive, but to
describe the types of
uses and disclosures
that may be made by our
office.
Treatment.
We will use and disclose
your protected health
information to provide,
coordinate or manage
your health care and any
related services. This
includes the
coordination or
management of your
health care with a third
party that may need
access to your protected
health information. For
example, we would
disclose your protected
health information, as
necessary, to a home
health agency that
provides care to you. We
will also disclose
protected health
information to other
physicians who may be
treating you. For
example, your protected
health information may
be provided to a
physician to whom you
have been referred to
ensure that the
physician has the
necessary information to
diagnose or treat you.
In addition, we may
disclose your protected
health information from
time-to-time to another
physician or health care
provider (e.g., a
specialist or
laboratory) who, at the
request of your
physician, becomes
involved in your care by
providing assistance
with your health care
diagnosis or treatment
to your physician.
Payment.
Your protected health
information will be
used, as needed, to
obtain payment for your
health care services.
This may include certain
activities that your
health insurance plan
may undertake before it
approves or pays for the
health care services we
recommend for you such
as: making a
determination of
eligibility or coverage
for insurance benefits,
reviewing services
provided to you for
medical necessity and
undertaking utilization
review activities. For
example, obtaining
approval for a hospital
stay may require that
your relevant protected
health information be
disclosed to the health
plan to obtain approval
for the hospital
admission.
Healthcare Operations.
We may use or disclose,
as needed, your
protected health
information in order to
support the business
activities of your
physician’s practice.
These activities
include, but are not
limited to, quality
assessment activities,
employee review
activities, training of
medical students,
licensing, and
conducting or arranging
for other business
activities.
For example, we may
disclose your protected
health information to
medical school students
that see patients at our
office. In addition, we
may use a sign-in sheet
at the registration desk
where you will be asked
to sign your name and
indicate your physician.
We may also call you by
name in the waiting room
when your physician is
ready to see you. We may
use or disclose your
protected health
information, as
necessary, to contact
you to remind you of
your appointment.
We will share your
protected health
information with third
party “business
associates” that perform
various activities
(e.g., billing,
transcription services)
for the practice.
Whenever an arrangement
between our office and a
business associate
involves the use or
disclosure of your
protected health
information, we will
have a written contract
that contains terms that
will protect the privacy
of your protected health
information.
We may use or
disclose your protected
health information, as
necessary, to provide
you with information
about treatment
alternatives or other
health-related benefits
and services that may be
of interest to you. We
may also use and
disclose your protected
health information for
other marketing
activities. For example,
your name and address
may be used to send you
a newsletter about our
practice and the
services we offer. We
may also send you
information about
products or services
that we believe may be
beneficial to you. You
may contact our Privacy
Contact to request that
these materials not be
sent to you.
We may use or
disclose your
demographic information
and the dates that you
received treatment from
your physician, as
necessary, in order to
contact you for
fundraising activities
supported by our office.
If you do not want to
receive these materials,
please contact our
Privacy Contact and
request that these
fundraising materials
not be sent to you.
Uses and Disclosures of
Protected Health
Information Based Upon
Your Written
Authorization.
Other uses and
disclosures of your
protected health
information will be made
only with your written
authorization, at any
time, in writing, except
to the extent that your
physician or the
physician’s practice has
taken an action in
reliance on the use or
disclosure indicated in
the authorization.
Other Permitted and
Required Uses and
Disclosures that may be
made without Your
Authorization or
Opportunity to Object.
We may use and
disclose your protected
health information in
the following instances.
You have the opportunity
to agree or object to
the use or disclosure of
all or part of your
protected health
information. If you are
not present or able to
agree or object to the
use or disclosure of the
protected health
information, than your
physician may, using
professional judgment,
determine whether the
disclosure is in your
best interest. In this
case, only the protected
health information that
is relevant to your
health care will be
disclosed.
Facility
Directories.
Unless you object, we
will use and disclose in
our facility directory
your name, the location
at which you are
receiving care, your
condition (in general
terms), and your
religious affiliation.
All of this information,
except religious
affiliation, will be
disclosed to people that
ask for you by name.
Members of the clergy
will be told your
religious affiliation.
Others Involved in Your
Healthcare. 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 information 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 your
professional judgment.
We may use or disclose
protected health
information to notify or
assist in notifying a
family member, personal
representative or any
other person that is
responsible for your
care of your location,
general condition or
death. Finally, we may
use or disclose your
protected health
information to an
authorized public or
private entity to assist
in disaster relief
efforts and to
coordinate uses and
disclosures to family or
other individuals
involved in your health
care.
Emergencies. We may use
or disclose your
protected health
information in an
emergency treatment
situation. If this
happens, your physician
shall try to obtain your
acknowledgement of our
Privacy Practices as
soon as reasonably
practicable after the
delivery of treatment.
If your physician has
attempted to obtain your
acknowledgement, but is
unable, he or she may
still use or disclose
your protected health
information for
treatment, payment, and
health care operations.
Communication
Barriers. We
may use and disclose
your protected health
information if your
physician or another
physician in the
practice attempts to
obtain an
acknowledgement of our
Privacy Practices from
you, but is unable to do
so due to substantial
communication barriers.
Other Permitted and
Required Uses and
Disclosures that may be
made without Your
Consent, Authorization
or Opportunity to
Object.
We may use or
disclose your protected
health information in
the following situations
without your
acknowledgement or
authorization. These
situations include:
Required By
Law. We may use
or disclose your
protected health
information to the
extent that the use or
disclosure is required
by law. The use or
disclosure will be made
in compliance with the
law and will be limited
to the relevant
requirements of the law.
You will be notified, as
required by law, of any
such uses or
disclosures.
Public Health.
We may disclose your
protected health
information for public
health activities and
purposes to a public
health authority that is
permitted by law to
collect or receive the
information. The
disclosure will be made
for the purpose of
controlling disease,
injury or disability. We
may also disclose your
protected health
information, if directed
by the public health
authority, to a foreign
government agency that
is collaborating with
the public health
authority.
Communicable
Diseases. We
may disclose your
protected health
information, if
authorized by law, to a
person who may have been
exposed to a
communicable disease or
may otherwise be at risk
of contracting or
spreading the disease or
condition.
Health Oversight. We may
disclose protected
health information to a
health oversight agency
for activities
authorized by law, such
as audits,
investigations, and
inspections. Oversight
agencies seeking this
information include
government agencies that
oversee the health care
system, government
benefit programs, other
government regulatory
programs and civil
rights laws.
Abuse or
Neglect. We may
disclose your protected
health information to a
public health authority
that is authorized by
law to receive reports
of child abuse or
neglect. In addition, we
may disclose your
protected health
information if we
believe that you have
been a victim of abuse,
neglect or domestic
violence to the
governmental entity or
agency authorized to
receive such
information. In this
case, the disclosure
will be made consistent
with the requirements of
applicable federal and
state laws.
Food and Drug
Administration.
We may disclose your
protected health
information to a person
or company required by
the Food and Drug
Administration to report
adverse events, product
defects or problems,
biologic product
deviations; track
products; to enable
product recalls; to make
repairs or replacements;
or to conduct post
marketing surveillance,
as required.
Legal
Proceedings. We
may disclose protected
health information in
the course of any
judicial or
administrative
proceeding, in response
to an order of a court
or administrative
tribunal (to the extent
such disclosure is
expressly authorized),
in certain conditions in
response to a subpoena,
discovery request or
other lawful process.
Law Enforcement. We may
also disclose protected
health information, so
long as applicable legal
requirements are met,
for law enforcement
purposes. These law
enforcement purposes
include: (1) legal
processes and otherwise
required by law, (2)
limited information
requests for
identification and
location purposes, (3)
pertaining to victims of
a crime, (4) suspicion
that death has occurred
as a result of criminal
conduct, (5) in the
event that a crime
occurs on the premises
of the practice, and (6)
medical emergency (not
on the practice’s
premises) and it is
likely that a crime has
occurred.
Coroners,
Funeral Directors, and
Organ Donation.
We may disclose
protected health
information to a coroner
or medical examiner for
identification purposes,
determining cause of
death or for the coroner
or medical examiner to
perform other duties
authorized by law. We
may also disclose
protected health
information to a funeral
director, as authorized
by law, in order to
permit the funeral
director to carry out
his/her duties. We may
disclose such
information in
reasonable anticipation
of death. Protected
health information may
be used and disclosed
for cadaveric organ, eye
or tissue donation
purposes.
Research.
We may disclose your
protected health
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
protected health
information.
Criminal Activity.
Consistent with
applicable federal and
state laws, we may
disclose your protected
health information if we
believe that the use or
disclosure is necessary
to prevent or lessen a
serious and imminent
threat to the health or
safety of a person or
the public. We may also
disclose protected
health information if it
is necessary for law
enforcement authorities
to identify or apprehend
an individual.
Military
Activity and National
Security. When
the appropriate
conditions apply, we may
use or disclose
protected health
information of
individuals who are
Armed Forces personnel:
(1) for activities
deemed necessary by
appropriate military
command authorities; (2)
for the purpose of a
determination by the
Department of Veterans
Affairs of your
eligibility for
benefits; or (3) to
foreign military
authority if you are a
member of that foreign
military services. We
may also disclose your
protected health
information to
authorized federal
officials for conducting
national security and
intelligence activities,
including for the
provision of protective
services to the
President or others
legally authorized.
Workers
Compensation.
Your protected health
information may be
disclosed by us as
authorized to comply
with workers’
compensation laws and
other similar legally
established programs.
Inmates.
We may use or disclose
your protected health
information if you are
an inmate of a
correctional facility
and your physician
created or received your
protected health
information in the
course of providing care
to you.
Required Uses
and Disclosures.
Under the law, we must
make disclosures to you
and when required by the
Secretary of the
Department of Health and
Human Services to
investigate or determine
our compliance with the
requirements of federal
regulations that protect
the privacy of your
protected health
information.
2. Your Rights
Following is a
statement of your rights
with respect to your
protected health
information and a brief
description of how you
may exercise these
rights.
You have the right to
inspect and copy your
protected health
information. This means
you may inspect and
obtain a copy of
protected health
information about you
that is contained in a
designated record set
for as long as we
maintain the protected
health information. A
“designated record set”
contains medical and
billing records and any
other records that your
physician and the
practice uses for making
decisions about you.
Under federal law,
however; you may not
inspect or copy the
following records:
psychotherapy notes;
information compiled in
reasonable anticipation
of, or use in, a civil,
criminal, or
administrative action or
proceeding; and
protected health
information that is
subject to law that
prohibits access to
protected health
information. Depending
on the circumstances, a
decision to deny access
may be reviewable. In
some circumstances, you
may have a right to have
this decision reviewed.
Please contact our
Privacy Contact if you
have questions about
access to your medical
record.
You have the right to
request a restriction of
your protected health
information. This means
you may ask us not to
use or disclose any part
of your protected health
information for the
purposes of treatment,
payment or healthcare
operations. You may also
request that any part of
your protected health
information not be
disclosed to family
members or friends who
may be involved in your
care or for notification
purposes as described in
this Notice of Privacy
Practices. Your request
must state the specific
restriction requested
and to whom you want the
restriction to apply.
Your physician is not
required to agree to a
restriction that you may
request. If a physician
believes it is in your
best interest to permit
use and disclosure of
your protected health
information, your
protected health
information will not be
restricted. If your
physician does agree to
the requested
restriction, we may not
use or disclose your
protected health
information in violation
of that restriction
unless it is needed to
provide emergency
treatment. With this in
mind, please discuss any
restriction you wish to
request with your
physician. You may
request a restriction by
submitting a written
request to our Privacy
Contact.
You have the right to
request to receive
confidential
communications from us
by alternative means or
at an alternative
location. We will
accommodate reasonable
requests. We may also
condition this
accommodation by asking
you for information as
to how payment will be
handled or specification
of an alternative
address or other method
of contact. We will not
request an explanation
from you as to the basis
for the request. Please
make this request in
writing to our Privacy
Contact.
You may have the
right to have your
physician amend your
protected health
information. This means
you may request an
amendment of protected
health information about
you in a designated
record set for as long
as we maintain this
information. In certain
cases, we may deny your
request for an
amendment. If we deny
your request for
amendment, you have the
right to file a
statement of
disagreement with us and
we may prepare a
rebuttal to your
statement and will
provide you with a copy
of any such rebuttal.
Please contact our
Privacy Contact if you
have questions about
amending your medical
record.
You have the right to
receive an accounting of
certain disclosures we
have made, if any of
your protected health
information. This right
applies to disclosures
for purposes other than
treatment, payment or
healthcare operations
and valid authorizations
or incidental
disclosures as described
in this Notice of
Privacy Practices. It
excludes disclosures we
may have made to you,
for a facility
directory, to family
members or friends
involved in your care,
or for notification
purposes. You have the
right to receive
specific information
regarding these
disclosures that
occurred after April 14,
2003. You may request a
shorter timeframe. The
right to receive this
information is subject
to certain exceptions,
restrictions and
limitations.
You have the right to
obtain a paper copy of
this notice from us,
upon request, even if
you have agreed to
accept this notice
electronically.
3. Complaints
You may complain to
us or to the Secretary
of Health and Human
Services if you believe
your privacy rights have
been violated by us. You
may file a complaint
with us by notifying our
Privacy Contact of your
complaint. We will not
retaliate against you
for filing a complaint.
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