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. If you have any questions, please contact our Practice Manager at the address or phone number at the end of this notice:

Our pledge to you:

We understand that medical information about you is personal. We are committed to protecting medical information about. We create a record of care and services to provide quality care and to comply with the legal requirements. This notice applies to all records of your care generated by Central Connecticut Foot Care Center, LLC. We are required by law to:

• Keep medical information about you private
• Give you this notice of our legal duties and privacy practices with respect to medical information about you, and
• Follow the terms of this notice that are currently in effect

How we may use and disclose medical information about you:

• We may use and disclose medical information about you without your prior authorization for treatment (such as sending medical information about you to a specialist as part of a referral, and this may include psychiatric or HIV information needed for the purpose of your diagnosis and treatment), to obtain payment for treatment (such as sending billing information to your insurance company or Medicare), and to support our healthcare operations (such as comparing patient data to improve treatment methods or for professional education purposes). (Note: only limited psychiatric or HIV information may be disclosed for billing purposes without your authorization).
• Other examples of such uses and disclosures include contacting you for appointment reminders and telling you about or recommending possible treatment options, alternatives, health-related benefits or services that may be of interest to you.
• We may disclose medical information about you without your prior authorization for several other reasons. Subject to certain requirements, we may give our medical information about you (without prior authorization) for public health purposes, abuse or neglect reporting, health oversight audits or inspections, medical examiners, funeral arrangements and organ donation, workers’ compensation purposes, emergencies, national security and other specialized government functions, and for members of the Armed Forces as requires by Military Command Authorities. We also disclose medical information when required by law, such as in response to a request from law enforcement in specific circumstances, or in response to valid judicial or administrative orders or other legal process.
• We may disclose medical information about you to a friend sir family member whom you designate or in appropriate circumstances, unless you request a restriction. We may also disclose information to disaster relief authorities so that your family can be notified of your location and condition.
• Under certain circumstances, we may use and disclose health information about you for research purposes, subject to an approval process.
• In any other situation not covered by this notice, we will ask for your written authorization before using or disclosing medical information about you. If you choose to authorize or disclose, you can later revoke that authorization by notifying guys in writing about your decision.

Right to Access and/or amend your Records:

• In most cases you have the right to look at or get a copy of medical information that we may use to make decisions about your care, when you submit a written request. If you request copies, we may charge a fee for the cost of copying, mailing, or other related supplies. If we deny your request or obtain a copy, you may submit a written request for a review of that decision.
• If you believe that information in your record is incorrect or that important information is missing, you have the right to request that we correct the records, by submitting a request in writing that provides the reason for requesting the amendment. We could deny your request to amend a record if the information is not maintained by us; or if we determine that your record is accurate. You may submit a written statement of disagreement with a decision by us not to amend a record.

Right to an Accounting:

• You have the right to request a list accounting any disclosures of your health information we have made, except for uses and disclosures for treatment, payment, and healthcare operations, circumstances in which you have specifically authorized such disclosure, and certain other exceptions.
• To request this list of disclosures, indicate the relevant period, which must be after November 1, 2006, but in no event for more than six years. You must submit your request in writing to the Practice Manager listed below.

Request for Confidential Communication:

You have the right to request that medical information about you be communicated to you in a confidential manner, such as sending mail to an address other than your home, by notifying us in writing of the specific way or location for us to use to communicate with you.

Changes to this Notice:

We may change our policies at any time. Changes will apply to medical information we already hold, as well as new information after the change occurs. Before we make significant changes in our policies, we will change our notice and post the new notice in the waiting area. You can receive a copy of the current notice at any time. The effective date listed at the end. Copies of the current notice will be available each time you come to our facility for treatment. You will be asked to acknowledge in writing your receipt of this notice.

Complaints:

• If you are concerned that your privacy rights may have been violated, or you disagree with a decision we made about access to your records, you may contact the Practice Manager listed below.
• If you are not satisfied with our response, you may send a written complaint to the U.S. Department of Health and Human Services Office of Civil Rights. Our Practice Manager can provide you with the address. Under no circumstance will you be penalized or retaliated against for filing a complaint

Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:

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.