Notice of Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully.
Your health record contains personal information about you and your health. State and federal law protects the confidentiality of this information. "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. If you suspect a violation you may file a report to the appropriate authorities in accordance with Federal regulations.
Your Rights regarding Your PHIYou have the following rights regarding PHI (Protected health information) I maintain about you:
My Uses and Disclosures of PHI for Treatment, Payment and Health Care Operations
Treatment. Your PHI may be used and disclosed by me for the purpose of providing, coordinating, or managing your health care treatment and any related services. This may include coordination or management of your health care with a third party, consultation with other health care providers or referral to another provider for health care services.
Payment. I will not use your PHI to obtain payment for your health care services without your written authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities.
Healthcare Operations. I may use or disclose, as needed, your PHI in order to support the business activities of my professional practice. Such disclosures could be to others for health care education, or to provide planning, quality assurance, peer review, administrative, legal, or financial services to assist in the delivery of health care, provided I have a written contract requiring the recipient(s) to safeguard the privacy of your PHI. I may also contact you to remind you of your appointments, inform you of treatment alternatives and/or health-related products or services that may be of interest to you.
Uses and Disclosures That Do Not Require Your Authorization or Opportunity to Object
Required by Law.
I may use or disclose your PHI to the extent that the use or disclosure is required by law, made in compliance with the law, and limited to the relevant requirements of the law. Examples are public health reports and law enforcement reports. I also must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining my compliance with the requirements of the Privacy Rule
I may disclose PHI to a health oversight agency for activities authorized by law, such as professional licensure. Oversight agencies also include government agencies and organizations that provide financial assistance to me (such as third-party payers).
Abuse or Neglect.
I may disclose your PHI to a state or local agency that is authorized by law to receive reports of abuse or neglect. However, the information I disclose is limited to only that information which is necessary to make the initial mandated report. Disclose PHI regarding deceased patients for the purpose of determining the cause of death, in connection with laws requiring the collection of death or other vital statistics, or permitting inquiry into the cause of death.
I may disclose PHI to researchers if (a) an Institutional Review Board reviews and approves the research and an authorization or a waiver to the authorization requirement; (b) the researchers establish protocols to ensure the privacy of your PHI; and (c) the researchers agree to maintain the security of your PHI in accordance with applicable laws and regulations.
Threat to Health or Safety.
I may disclose PHI when necessary to prevent a serious threat to your health and safety or the health and safety to the public or another person.
Criminal Activity on My Business Premises/Against Me and My Staff.
I may disclose your PHI to law enforcement officials if you have committed a crime on my premises or against me or my staff.
I will disclose your PHI if a court of competent jurisdiction issues an appropriate order. I will disclose your PHI if you and I have each been notified in writing at least fourteen in advance of a subpoena or other legal demand, and no protective order has been obtained, and I have satisfactory assurances that you have received notice of an opportunity to have limited or quashed the discovery demand.
Uses and Disclosures of PHI with Your Written Authorization
Other uses and disclosures of your PHI will be made only with your written authorization. You may revoke this authorization in writing at any time; unless I have taken an action in reliance on the authorization of the use or disclosure you permitted, such as providing you with health care services for which I must submit subsequent claim(s) for payment.
This Notice of Privacy Practices describes how I may use and disclose your protected health information
(PHI) in accordance with all applicable law. It also describes your rights regarding how you may gain access to and control your PHI. I am required by law to maintain the privacy of PHI and to provide you with notice of my legal duties and privacy practices with respect to PHI. I am required to abide by the - terms of this Notice of Privacy Practices. I reserve the right to change the terms of my Notice of Privacy Practices at any time. Any new Notice of Privacy Practices will be effective for all PHI that I maintain at that time. I will make available a revised Notice of Privacy Practices by providing one to you at your next appointment or mailing you a copy at your request.
I am my own Privacy Officer. So, if you have any questions about this Notice of Privacy Practices, please contact me. My contact information is on the letterhead at the beginning of this notice.
If you believe I have violated your privacy rights, you may file a complaint in, writing to me, as my own Privacy Officer, specified on the first page of this Notice. I will not retaliate against you for filing a complaint. You may also file a complaint with the U.S. Secretary of Health and Human Services.