HIPAA NOTICE OF PRIVACY PRACTICES

THIS NOTICE IS NOT A RELEASE OF YOUR MEDICAL INFORMATION

This Notice describes how we may use and disclose your protected health information

(PHI) 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. “PHI” 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 PHI 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 PHI 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 PHI, as necessary, to a home agency that provides care to you. For

example, your PHI 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 PHI 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 PHI be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations: We may use or disclose, as-needed, your PHI 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 PHI to medical 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 PHI in the following situations without your authorizations.

These situations include: 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: You have the right to inspect and copy your PHI, 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 PHI that is subject to law that prohibits access to PHI. You have the

right to request a restriction of your PHI. This means you may ask us not to use or disclose

any part of your PHI for the purposes of treatment, payment or healthcare operations. You

may also request that any part of your PHI 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 PHI, your PHI 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 PHI, 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've made, if

any of your PHI 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. 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 PHI.

If you have any objections to this form, please ask to speak with our HIPAA Compliance

Officer in person or by phone at (503) 404-4044.