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 medical provider or others working this office. This notice will inform you about the ways 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 health information. Follow the terms of the Notice of Privacy Practices 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, public health risks, health oversight activities, lawsuits and disputes, law enforcement, coroners, health examiners and funeral directors, to avert a serious threat to health and safety, as required by the military or veterans administration, national security, inmates, workers’ compensation.
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.
Changes to Notice of Privacy Practices:
We reserve the right to change this notice. We will post a copy of the current notice in our facility with the current effective date.
If you believe that your privacy rights have been violated you may file a complaint with us. All complaints must be in writing.
Acknowledgment of Receipt of this Notice:
We will request that you sign a separate form acknowledging you have received a copy of this notice. This acknowledgment will become part of your records.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.