SUMMARY OF NOTICE OF PRIVACY PRACTICES
This summary is provided to assist you in understanding the Notice of Privacy Practices
The Notice of Privacy Practices contains a detailed description of how our office will protect your health information., your rights as a patient and our common practice in dealing with patient health information.
Uses and Disclosures of Health Information
We will use and disclose you health information in order to treat you or to assist other health care providers in treating you. We will also use and disclose your health information in order to obtain payment for our services or to allow insurance companies to process insurance claims for services rendered to you by is or other health care providers. Finally, we may disclose your health information for certain limited operational activities such as quality assessment, licensing, accreditation and training of students.
Uses and Disclosures Based on Your Authorization
Except as stated in more detail in the Notice of Privacy Practices, we will no use or disclose your health information without your written authorization.
Uses and Disclosures Note Requiring Your Authorization
In the following circumstances, we may disclose your health information without your written authorization:
- To family members or close friends who are involved in your health care;
- For certain limited research purposes;
- For purposes of public health and safety;
- To Government agencies for purposes of their audits, investigations and other oversight activities;
- To government authorities to prevent child abuse or domestic violence;
- To the FDA to report product defects or incidents;
- To law enforcement authorities to protect public safety or to assist
- in apprehending criminal offenders;
- When required by court orders, search warrants, subpoenas and as otherwise required by law.
As our patient, you have the following rights:
- To have access to and/or a copy of your health information;
- To receive an accounting of certain disclosures we have made of your health information;
- To request restrictions as to how your health information is used or disclosed;
- To request that we communicate with your confidence;
- To request that we amend your health information;
- To receive notice of our privacy practices.
If you have a question, concern or complaint regarding our privacy practices, please refer to the Notice of Privacy Practices for the person or person whom you may contact.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read (or had the opportunity to read if I so chose) and understood the Notice.