Forms

Notice of Privacy Practices

This Notice is being provided to you as part of our compliance with a series of Federal Regulations which fall under what is described as HIPAA rules. HIPAA stands for the Health Insurance Portability and Accountability Act. The rules mandating this notice are only part of the HIPAA regulations. You may be provided other documents as part of our effort to stay in compliance with these laws. The regulations also require we obtain from you a signed acknowledgement that you have been provided this information. This form is included in this packet.

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 document carefully.

If you have any questions about this notice please contact the office manager of the location you normally receive services.

This Notice of Privacy Practices describes how we may use and disclose your protected health information 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. 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 condition and related health care services.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time. The new notice will be effective for all protected health information that we maintain at that time. Upon your request, we will provide you with any revised Notice of Privacy Practices. This request may be made by calling the office and requesting that a revised copy be sent to you in the mail. You may also ask for a copy at the time of your next appointment.

The following is a condensed version of our Notice of Privacy Practices. It is being provided to you in accordance with the regulations set forth under HIPAA. Our complete Notice of Privacy Practices is  available upon request in any of our offices.

Uses and Disclosures of Protected Health Information with or without your Written Consent

Revisions to HIPAA regulations published in the August 14, 2002 Federal Register indicate that Protected Health Information may be disclosed without consent so long as disclosures are made in connection with routine health care delivery purposes.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services.

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, employee review, employee training and licensing.

Other Permitted and required uses and disclosures that may be made with your consent, authorization or opportunity to object.

We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then your physician may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.

Others involved in your healthcare: Unless you object, we may disclose to a member of your family, a close friend or any other person you identify, your protected health information that directly relates to that persons involvement in your health care.

Emergencies: We may use or disclose your protected health information in an emergency treatment situation.

Communication Barriers: We may use or disclose your protected health information if your physician or another physician within this practice attempts to obtain consent from you but is unable to do so due to substantial communication barriers and the physician determines, using professional judgment, that you intend to consent to use or disclosure under the circumstances.

Other permitted and required uses and disclosures that may be made without your consent, authorization or opportunity to object.

We may use or disclose your protected health information in the following situations without your consent or authorization. These situations include:

Required by law: We may use or disclose your protected health information to the extent that the use or disclosure is required by law. You will be notified of any such disclosures.

Public Health: We may use or disclose your protected health information for public health activities and purposes to a public health authority that is permitted by law to collect or receive the information.

Communicable Diseases: We may disclose your protected health information, if authorized by law, to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition.

Health oversight: We may disclose your protected health information to a health oversight agency for activities authorized by law, such as audits, investigations and inspections.

Abuse or Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of child abuse or neglect.

Food and Drug Administration: We may disclose your protected health information to a person or company required by the FDA to report adverse events, product defects or problems, etc.

Legal Proceedings: We may disclose your protected health information in the course of any judicial or administrative proceeding, in response to an order of the court.

Law Enforcement: We may disclose your protected health information for law enforcement purposes.

Coroners, Funeral Directors, and Organ Donations: We may disclose your protected health information to a coroner or medical examiner for identification purposes, determining cause of death or for the performance of duties authorized by law.

Research: We may disclose your protected health information to researchers when their research has been approved by an institutional review board.

Criminal Activity: We may disclose your protected health information if we believe that the use is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.

Military Activity and National Security: We may disclose your protected health information if you are a member of the Armed Forces and certain conditions apply.

Workers Compensation: We may disclose your protected health information to comply with workers compensation laws.

Your Rights

• You have the right to inspect and copy your protected health information.
• You have the right to request a restriction of your protected health information.
• You have the right to request to receive confidential communications from us by alternative means or at an alternative location.
• You may have the right to have your physician amend your protected health information.
• You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.
• You have the right to obtain a paper copy of this notice from us.

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.

Further information about the complaint process can be obtained by contacting the office manager of the location at which you receive services. The manager will work with our privacy officer to address your concerns.