HIPAA Notice of Privacy Practices
This notice describes how your medical information may be used, disclosed and how you can access this information. Please review 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.
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.
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
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
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.
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 call our
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