HIPAA Notice of Privacy Practices

We understand that health information about you and your health is personal. We are committed to protecting health information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This Notice applies to all of the records of your care generated by this office, whether made by your personal doctor or others working in this office. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information.

We are required by law to:

• Make sure that health information that identifies you is kept private
• Give you this Notice of our legal duties and privacy practices with respect to your health information
• Follow the terms of the Notice that is currently in effect.

How we may use and disclose health information about you:

• For treatment
• For payment
• For health care operations
• For appointment reminders
• As required by Law
• To avert a serious threat to health and safety
• As required by the Military or Veterans and Workers Compensation
• Public Health risks
• Health oversight activities
• Lawsuits and disputes
• Law enforcement
• Coroners, health examiners and funeral directors
• National Security and Intelligence activities
• Protective Services for the President and others
• Security Officials for Inmates

Your rights regarding Health Information about you:

• Right to Inspect and Copy
• Right to Amend
• Right to an Accounting of Disclosures
• Right to Request Restrictions
• Right to Request Confidential Communications
• Right to a Paper copy of this Notice (full Notice is available upon request)

Complaints:

If you believe that your privacy rights have been violated, you may file a complaint with us. All complaints must be in writing. Please contact Dr. Burkart at the address below to file a complaint.

Acknowledgement of Receipt of this Notice:

We will request that you sign a separate form acknowledging you have received a copy of this notice. This acknowledgement will become part of your records. This acknowledgment provides that you have declined to accept the Compete Notice and instead requested this Short Form. We keep copies of the Current Complete Notice of Privacy Practices in our office and you may ask for a copy.