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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.
This
Notice of Privacy Practices describes how we may use and
disclose your protected health information (PHI) to
carry out treatment, payment or health care operations (TPO)
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.
1. Uses and Disclosures
of Protected Health Information
Uses and Disclosures of
Protected Health Information
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, to pay your health care bills, to
support the operation of the physician’s practice, and
any other use required by law .
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. For example, we would disclose your
protected health information, as necessary, to a home
health agency that provides care to 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.
Payment:
Your protected health information will be used, as
needed, to obtain payment for your health care services.
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 may use or
disclose your protected health information in the
following situations without your authorization. These
situations include: as Required By Law, Public Health
issues as required by law, Communicable Diseases: Health
Oversight: Abuse or Neglect: Food and Drug
Administration requirements: Legal Proceedings: Law
Enforcement: Coroners, Funeral Directors, and Organ
Donation: Research: Criminal Activity: Military Activity
and National Security: Workers’ Compensation: Inmates:
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 Section 164.500.
Other
Permitted and Required Uses and Disclosures Will Be
Made Only With Your Consent, Authorization or
Opportunity to Object unless required by law.
You may revoke this 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.
Your Rights
Following is a statement of your rights with respect to
your protected health information.
You have the right to
inspect and copy your protected health information.
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.
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 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. You then have the
right to use another Healthcare Professional.
You have the right to
request to receive confidential communications from us
by alternative means or at an alternative location.
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 alternatively i.e.
electronically.
You may have the right
to have your physician amend your protected health
information.
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.
You have the right to
receive an accounting of certain disclosures we have
made, if any, of your protected health information.
We
reserve the right to change the terms of this notice and
will inform you by mail of any changes. You then have
the right to object or withdraw as provided in this
notice.
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.
This
notice was published and becomes effective on/or before
April 14,
2003.
We are required by law
to maintain the privacy of, and provide individuals
with, this notice of our legal duties and privacy
practices with respect to protected health information.
If you have any objections to this form, please ask to
speak with our HIPAA Compliance Officer in person or by
phone at our Main Phone Number.
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