This notice describes how health information about you may be used and disclosed and how you can get access to this information.
Please review this notice carefully. The privacy of your health information is important to us.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to provide this notice about our privacy practices, our legal duties and your rights concerning your health information. This notice takes effect on [date] and remains in effect until replaced.
We reserve the right to change our privacy practices and the terms of this notice at any time as applicable law permits. Any changes made effect all health information we maintain, including health information created or received before the change went into effect. Any changes will be reflected in this notice and the revised notice will be made available upon request.
You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for a variety of reasons. Typical situations are described below.
Treatment: We may use and disclose your health information to a physician or other healthcare provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluation practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
Communications: We may send appointment reminder postcards or leave voice mail messages reminding you of appointments or changes in appointments. We will use the phone numbers and address provided by you to send these communications. We may also have a sign-in sheet at the front desk of our office, where all patients sign in upon arrival.
Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any prior disclosures permitted by your authorization while it was in effect.
To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.
Persons Involved in Care: We may use or disclose health information to help locate you and determine your general health condition; we may also use of disclose information to help identify and/or locate a family member, personal representative or other person responsible for your care. If you are available and competent, you will be contacted for permission before the information is disclosed. If you are incapacitated or in an emergency situation, we will determine the need for disclosure based on our professional judgment.
Marketing Health Related Services: We will not use your health information for marketing communications without your written authorization.
Required by Law: We may use or disclose your health information when we are required to do so by law.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we have reason to believe that you are a possible victim of abuse, neglect, domestic violence or other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
National Security: We may disclose the health information of Armed Forces personnel to military authorities under certain circumstances. We may disclose health information required for lawful intelligence, counterintelligence and other national security activities to authorized federal officials. We may disclose protected health information to correctional institution or law enforcement officials who have lawful custody of a patient under certain circumstances.
PATIENT RIGHTS
Access: You have the right to look at and receive copies of your health information, with limited exceptions. Requests must be submitted in writing; send a letter or complete a request form provided by the practice. We may charge you a reasonable fee for staff time and materials; charges will vary depending on the details of your request. You may be charged per page or per hour of staff time for copying records, and for postage for mailing records to you or another provider. Additional charges may be incurred for requests for health information summaries, or providing records in alternative formats. Every effort will be made to honor requests unless we cannot practically do so. Contact the office for a complete explanation of our fee structure.
Disclosure Accounting: You have the right to receive a list of instances when we or our business associates disclosed your health information for purposes other than treatment, payment, healthcare operations and certain other activities. Records of this information are available from (date) onward. Reports are limited to six years of activity. One report request per year is complimentary; if you request this report more than once in a 12 month period, we may charge you a reasonable fee.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. Additional restriction requests must be submitted in writing. We are not required to agree to these additional restrictions. If we do, we will agree to them in writing.
Alternative Communication: You have the right to request that we communicate with you by alternative means or to alternative locations. You must make your request in writing. Your request must specify the alternative means or locations, and provide satisfactory explanation of how payments will be handled under the alternative circumstances.
Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.
Electronic Notice: If you receive this notice via our Web site or by electronic mail (e-mail), you are also entitled to request a notice in hard-copy format. Contact the office to receive a hard copy.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.