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.
We care about our patient’s privacy and strive to protect the confidentiality of your medical information at this practice. You have the right to the confidentiality of your medical information. Federal and state law requires us to abide by the terms of this Notice of Privacy Practices which summarizes your rights and our legal duties with respect to your protected health information. If you have any questions about this Notice, please contact the office staff or the physician at this practice.
Who must comply with this Notice: Any health care professional authorized to enter information into your medical record and all employees, staff, and other personnel at this practice who may need access to your information must abide by this Notice. All subsidiaries, business associates (e.g. a billing service), sites, and locations of this practice may share medical information with each other for treatment, payment purposes or health care operations described in this Notice. Except where treatment is involved, only the minimum necessary information needed to accomplish the task will be shared.
How we may use and disclose medical information about you: The following categories describe different ways the law allows us to use or disclose medical information without your specific consent or authorization. Examples are provided for each category of uses or disclosures. Not every possible use or disclosure in a category is listed.
• For treatment. We may use medical information about you to provide you with medical treatment or services. For example, in treating you for a specific condition, we may need to know if you have allergies that could influence which medications we prescribe for your treatment.
• For payment. We may use and disclose medical information about you so that the treatment and services you receive from us may be billed and payment may be collected from you, an insurance company or third party. For example, we may need to send your protected health information, such as your name, address, office visit date, and codes identifying your diagnosis and treatment to your insurance company for payment.
• For other health care operations. We may use and disclose medical information about you for health care operations to ensure that you receive quality care. For example, we may use medical information to review our treatment and services and evaluate the performance of our staff in caring for you.
• Other uses and disclosures that can be made without consent or authorization. The law allows us to use and disclose health information without your consent or authorization under the following additional circumstances:
o as required during an investigation by law enforcement agencies
o to avert a serious threat to public health and safety
o as required by military command authorities for their medical records
o to workers’ compensation or similar programs for processing of claims
o in response to a legal proceeding
o to a coroner or medical examiner for identification of a body
o if an inmate, to the correctional institution or law enforcement official
o as required by the US Food and Drug Administration (FDA)
o other health care providers’ treatment activities
o other covered entities’ and providers’ payment activities
o other covered entities’ healthcare operations activities ( to the extent permitted under HIPAA)
o uses and disclosures required by law
o uses and disclosures in domestic violence or neglect situations
o health oversight activities
o other public health activities
Uses and disclosures of protected health information requiring your written authorization. Other uses of medical information not covered by this notice or the laws that apply to us will be made only with your written authorization. If you give us the authorization to use and disclose medical information about you, you can revoke that authorization, at any time. If you revoke your authorization, we will thereafter no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your written authorization and that we are required to retain our records of the care we provided to you.
Individual rights regarding your medical information. The law grants to you several individual rights concerning your health records, including:
• Complaints. If you believe your privacy rights have been violated, you may file a complaint with our office staff at this practice. All complaints must be submitted in writing. You will not be penalized or discriminated against for filing a complaint.
• Right to request restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations or to someone who is involved in your care or the payment for your care. We are not required to agree to your request. However, if we do agree, we will comply with your request unless the restricted information is needed to provide you with emergency treatment. To request restrictions or limitations, you must submit your request in writing and specify the information you want to limit.
• Right to request confidential communications. You have a right to request how we should send communications to you about medical matters and where you would like to have those communications sent. To request confidential communications, you must make your request to the office staff at this practice. We will not ask you for the reasons of your request. We will accommodate all reasonable requests. Your requests must specify how or where you wish to be contacted. We reserve the right to deny a request if it imposes an unreasonable burden on the practice.
• Right to inspect and copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually this includes medical and billing records but does not include psychotherapy notes, information compiled for use in a civil, criminal or administrative proceeding, and protected information to which access is prohibited by law. To inspect and copy medical information that may be used to make decisions about you, you must submit a written request. If you request a copy of the information, we have a right to charge a fee for the cost of copying, mailing and other supplies associated with your request. We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical information, you may request that denial to be reviewed. Another licensed health care professional, not involved with the original decision, will review the denial of your request. Our office will comply with the outcome of the review and provide the reviewer’s decision to you in writing.
• Right to amend. If you feel that the medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have a right to request an amendment for as long as the information is kept. To request an amendment, your request must be made in writing, include a reason that supports your request, and submitted to the office staff at this practice. We may deny your request for amendment if it is not in writing or does not include the reason to support the request. In addition, we may deny your request if the information was not created by us, is not part of the medical information kept at this practice, or is not part of the information that you would be permitted to inspect or copy. If we deny your request for amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Statements of disagreement and any corresponding rebuttals to your statement will be kept on file and sent out with any future authorized requests for information pertaining to the appropriate portion of the record.
• Right to an accounting for non-standard disclosures. You have the right to request a list of the disclosures we made of medical information about you. To request this list you must submit this request in writing to the staff at this practice. Your request must state a time period for which you want to receive a list of disclosures. The period may be for no longer than six years, and may not include dates before January 1, 2020, the date on which this practice was opened and before which we have no records. Your request should indicate whether you want the list in paper or electronic format. One list request per 12 month period will be provided free of charge. For more frequent requests, we reserve the right to charge for the cost of providing the list.
• Right to a paper copy of this notice. You have a right to a paper copy of this notice anytime. Even if you have agreed to this notice electronically, you are still entitled to a paper copy. To obtain a paper copy of the current notice, please request one in writing from the front desk.
Change to this notice. We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information already on file as well as any information we receive in the future. We will post a copy of current notice, with the effective date in the upper right corner of the first page.