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.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a federal
program that requires that all medical and dental records and other individually
identifiable health information used or disclosed by us in any form, whether
electronically, on paper or orally, are kept properly confidential. This Act gives you, the
patient, significant new rights to understand and control how your health information is
used. HIPAA provides penalties for covered entities that misuse Protected Health
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.
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 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, your
protected health information may be provided to a physician to whom you have been
referred to ensure that the health care professional has the necessary information to
diagnose or treat you.
Payment: Your protected health information will be used, as needed, to obtain payment
for 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, and conducting or arranging for other business activities. We may use or
disclose, as needed, your protected health information to support the business activities
of this practice. 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 call your home and leave a message (either on an
answering machine or with the person answering the phone) to remind you of an
upcoming appointment, the need to schedule a new appointment or to call our office.
We may also mail a postcard reminder to your home address. If you would prefer that
we call or contact you at another telephone number or location, please let us know.
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 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 HIPAA.
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.
The Following is a statement of your rights with respect to your protected health
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 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 you care or for notification purposes described in this
Notice of Privacy Practices. Your request must state the specific restriction and to whom
you want the restriction to apply.
Your physician is not required to agree to a restriction you may request. If your
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 of any
changes. You then have the right to object or withdraw as provided in this Notice.
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 officer of your complaint at our office and main telephone
number. We will not retaliate against you for filing a complaint.