Practice Privacy Notice

    Notice of Privacy Practices


EFFECTIVE DATE:  September 1, 2013






The practice provides this Notice to comply with the Privacy Regulations issued by the Department of Health and Human Services in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).


We understand that your medical information is personal to you and we are committed to protecting the information about you.  As our patient, we create paper and electronic medical records about your health, our care for you, and the services and/or items we provide to you as our patient.  We need this record to provide for your care and to comply with certain legal requirements.




The following categories describe different ways that we use and disclose protected health information that we have and share with others.  Each category of uses or disclosures provides a general explanation and provides some examples of uses.  Not every use or disclosure in a category is either listed or actually in place.  The explanation is provided for your general information only.


Medical Treatment.

We use previously given medical information about you to provide you with current or prospective medical treatment or services.  Therefore we may, and most likely will, disclose medical information about you to doctors, nurses, technicians, medical students, or hospital personnel who are involved in taking care of you.  For example, a doctor to whom we refer you for ongoing or further care may need your medical record.

We may also discuss your medical information with you to recommend possible treatment options or alternatives that may be of interest to you.  We also may disclose medical information about you to people outside the practice who may be involved in your medical care after you leave the practice; this may include your family members, or other personal representatives authorized by you or by a legal mandate (a guardian or other person who has been named to handle your medical decisions should you become incompetent).


Payment.  We may use and disclose medical information about you for services and procedures so that they may be billed and collected from your insurance company or any other third party.  For example, we may need to give your healthcare information about treatment you received to obtain payment or reimbursement for the care.  We may also tell your health plan and\or referring physician about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment to facilitate payment of a referring physician, or the like.


HealthCare Operations.   We may use and disclose medical information about you so that we can run our practice more efficiently and make sure that all of our patients receive quality care.  These uses may include reviewing our treatment and services to evaluate the performance of our staff, deciding what additional services to offer and where, deciding what services are not needed, and whether certain new treatments are effective.  We may also disclose information to other medical personnel for review and learning purposes.  We may combine the medical information we have with medical information from other practices to compare how we are doing and see where we can make improvements in the care and services we offer.  We may remove information that identifies you from this set of medical information so others may use it to study healthcare and healthcare delivery without learning who the specific patients are.


Appointment and Patient Recall Reminders.   We may use and disclose medical information to contact you as a reminder that you have an appointment for medical care or that you are due to receive periodic care.  This contact may be by phone, in writing, e-mail, or otherwise  may involve the leaving an e-mail message, a message on an answering machine, or otherwise, which could (potentially) be received or intercepted by others.


Emergency situations.  In addition, we may disclose medical information about you to an organization assisting in a disaster relief effort or in an emergency situation so that your family can be notified about your condition, status and location.


Required by Law.  We will disclose medical information about you when required to do so by federal, state, or local law.


To Avert a Serious Threat to Health or Safety.  We may use and disclose medical information about you when necessary to prevent a serious threat either to your specified health and safety, or the health and safety of the public or another person.  Any disclosure, however, would only be to someone able to help prevent the threat.


Business Associates.  We may disclose health information to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.  For example, we may use another company to perform billing services on our behalf.  All of our business associates are obligated to protect the privacy of your information, and are not allowed to use or disclose any information other than as specified in our contract.


Organ and Tissue Donation.  If you are an organ donor, we may use or release health information to organizations that handle organ procurement and other entities engaged in procurement; banking or transportation of organs, eyes or tissues to facilitate organ, eye or tissue donation and transportation.


Military and Veterans.  If you are a member of the armed forces we may release health information as required by military command authorities.  If you are a member of a foreign military we may release health information to the appropriate foreign military authority.


Workers’ Compensation.  We may release medical information about you for workers’ compensation or similar programs.  These programs provide benefits for work related injuries or illness.


Public Health Risks.  Law or public policy may require us to disclose medical information about you for public health activities.  The activities generally include the following:

  1. To prevent or control disease, injury or disability.
  2. To report child abuse or neglect.
  3. To report reactions to medications or problems with products.
  4. To notify people of recalls of products they may be using.
  5. To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.
  6. To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.


Investigation and Government Activities.  We may disclose medical information to a local, state, or federal agency for activities authorized by law.  These may include; audits, investigations, inspections, and licensure.  These activities are necessary for the payor, the government, and other regulatory agencies to monitor the healthcare systems, government programs, and compliance with civil rights laws.


Data Breach Notification Purposes.  We may use or disclose your protected health information to provide legally required notices of unauthorized access to or disclosure of your health information.


Lawsuits and Disputes.  If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order.  This is especially true if you make your health an issue.  We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in a dispute.  We shall attempt, in these cases, to tell you about the request so that you may obtain an order protecting the information requested if you so desire.  We may also use such information to defend ourselves or any member of our practice in any actual or threatened action.


Coroners, Medical Examiners and Funeral Directors.  We may release health information to a coroner or medical examiner.  This may be necessary to identify a deceased person or determine the cause of death.  We also may release health information to a funeral director as necessary for their duties.


National Security and Intelligence Activities.  We may release health information to authorized federal officials for intelligence, counter-intelligence, and other national security activities authorized by law.


Protective Services for the President and Others.  We may disclose health information to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state, to conduct special investigations.


Law Enforcement.  We may release medical information if asked to do so by a law enforcement official:

  1. In response to a court order, subpoena, warrant, summons or similar process.
  2. To identify or locate a suspect, fugitive, material witness, or missing person.
  3. About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement.
  4. About the death we believe may be the result of criminal conduct.
  5. About criminal conduct at the practice.
  6. In emergency circumstances to report a crime, the location of the crime or victims, or the identity, description and location of the person who committed the crime.


Inmates.  If you are an inmate of a correctional institution or under the custody of the law enforcement official, we may release medical information about you to the correctional institution or law enforcement official.  This release would be necessary for the institution to provide you with healthcare, to protect your health and safety or the health and safety of others or for the safety and security of the correctional institution.




Individuals Involved in Your Care or Payment for Your Care.  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 healthcare.  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 our professional judgment.


Disaster Relief.  We may disclose your protected health information to disaster relief organizations that seek your protected health information to coordinate your care, or notify family and friends of your location or condition in a disaster.  We will provide you with an opportunity to agree or object to such a disclosure whenever we practically can do so.



Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission, unless those uses can be reasonably inferred from the intended uses above.  If you have provided us with your permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time.  If you revoke your permission, we will 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 permission, and that we are required to retain our records of the care that we provided to you.




You have the following rights regarding Health Information we have about you.


Right to Inspect and Copy.  You have a right to inspect and copy health information that may be used to make decisions about your care or payment for your care.  This includes medical and billing records, other than psychotherapy notes.  To inspect and copy this health information, you must make your request in writing to the practice. We have up to 30 days to make your protected health information available to you, and we may charge you a reasonable fee for the costs of copying, mailing or other supplies associated with your request.  We may not charge you a fee if you need the information for a claim for benefits under the Social Security Act or any other state or federal needs based benefit program.  We may deny your request in certain limited circumstances.  If we do deny your request, you have the right to have the denial reviewed by a licensed healthcare professional who was not directly involved in the denial of your request, and we will comply with the outcome of the review.


Right to an Electronic Copy of Electronic Medical Records.  If your protected health information is maintained in an electronic format (known as an electronic medical record or an electronic health record), you have the right to request that an electronic copy of your record be given to you or transmitted to another individual or entity.  We will make every effort to provide access to your protected health information in the form or format you request, if it is readily producible in such form or format.  If the protected health information is not readily producible in the form or format you request your record will be provided in either our standard electronic format, or if you do not want this form or format, a readable hard copy form.  We may charge you a reasonable, cost-based fee for the labor associated with transmitting the electronic medical record.


Right to Get Notice of a Breach.  You have the right to be notified upon a breach of any of your unsecured protected health information.


Right to Amend.  If you feel that health information we have is incorrect or incomplete, you may ask us to amend the information.  You have the right to request an amendment for as long as the information is kept by or for our office.  To request an amendment, you must make your request in writing to the practice.


Right to an Account of Disclosures.  You have the right to request a list of certain disclosures we made of health information for purposes other than treatment, payment and healthcare operations, or for which you provided written authorization.  To request an accounting of disclosures, you must make your request in writing to the practice.


Right to Request Restrictions.  You have the right to request a restriction or limitation on the health information we use or disclose for treatment, payment or healthcare operations. You also have the right to request a limit on the health information we disclose to someone involved in your care or the payment for your care, like a family member or friend.  For example, you could ask that we not share information about a particular diagnosis with your spouse.  To request a restriction, you must make your request in writing to the practice.  We are not required to agree to your request unless you are asking us to restrict the use and disclosure of your protected health information to a health plan for payment for healthcare operation purposes, and such information you wish to restrict pertains solely to a healthcare item or service for which you have paid us “out of pocket” in full.  If we agree, we will comply with your request unless the information is needed to provide you with emergency treatment.


Out- of-Pocket-Payments.  If you paid out-of-pocket (and you have requested that we not bill your health plan) in full for a specific item or services, you have the right to ask that your protected health information, with respect to that item or service, not be disclosed to a health plan for purposes of payment or healthcare operations, and we will honor that request.


Right to request confidential communications.  You have the right to request that we communicate with you about medical matters in a certain way or at a certain location.  For example, you can ask that we only contact you by mail or at work.  To request confidential communications, you must make your request in writing to the practice.  Your request must specify how or where you wish to be contacted.  We will accommodate reasonable requests.


Right to a Paper Copy of this Notice.  You have the right to a paper copy of this notice.  You may ask us to give you a copy of this notice at any time.  Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.  You may obtain a copy of this notice at our website, or You may request a paper copy from the practice.




We reserve the right to change this notice at any time.  We reserve the right to make the revised or changed notice effective for medical information we already have about you, as well as any information we may receive from you in the future.  We will post a copy of the current notice in the practice.  The notice will contain on the first page, in the top right hand corner, the date of the last revision and effective date.  In addition, each time you visit the practice for treatment or health care services you may request a copy of the current notice in effect.




If you believe your privacy rights have been violated, you may file a complaint with the practice, or with the Secretary of the Department of Health and Human Services.  To file a complaint with the practice, contact our office manager, who will direct you on how to file a complaint.  All complaints must be submitted in writing, and all complaints shall be investigated, without repercussion to you. You will not be penalized for filing a complaint.



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