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1.
Uses
and Disclosures of Protected Health Information
Your protected heath information may be used and
disclosed by your physician, our office staff and
others outside our office that are involved in your
care and treatment for the purpose of providing health
care services to you, to pay your health care bills,
to support the operation of the physician’s practice,
and any other use required by law.
Treatment:
We will use and disclose your protected health
information to provide, coordinate, or manage your
health care and any related services. This includes
the coordination or management of your health care
with a third party. For example, we would disclose
your protected health information, as necessary, to a
home health agency that provides care to you. For
example, your protected health information may be
provided to a physician to whom you have been referred
to ensure that the physician has the necessary
information to diagnose or treat you.
Payment:
Your protected health information will be used, as
needed, to obtain payment for your health care
services. For example, obtaining approval for a
hospital stay may require that your relevant protected
health information be disclosed to the health plan to
obtain approval for the hospital admission.
Healthcare Operations: We may use or
disclose, as-needed, your protected health information
in order to support the business activities of your
physician’s practice. These activities include, but
are not limited to , quality assessment activities,
employee review activities, training of medical
students, licensing, and conducting or arranging for
other business activities. For example, we may
disclose your protected heath information to medical
school students that see patients at our office. In
addition, we may use a sign-in sheet at the
registration desk where you will be asked to sign your
name and indicate your physician. We may also call
you by name in the waiting room where your physician
is ready to see you. We may use or disclose your
protected health information, as necessary, to contact
you to remind you of your appointment.
We may use or disclose your protected health
information in the following situation without your
authorization. These situation include: as Required by
Law, Public Health issues as required by law,
Communicable Diseases: Health Oversight: Abuse or
Neglect: Food and drug Administration requirements:
Legal Proceedings: Law Enforcement: Coroners, Funeral
Directors, and Organ Donation: Research: Criminal
Activity: Military Activity and National Security:
Workers’ Compensation: Inmates: Required Uses and
Disclosures: Under the law, we must make disclosures
to you and when required by the Secretary of the
Department of Health and Human Services to investigate
or determine our compliance with the requirements of
Section 164.500
Other
Permitted and Required Uses and Disclosures: Will Be Made
Only With Your Consent, Authorization or Opportunity
to Object unless required by law.
You may
revoke this authorization at any time, in
writing, except to the extent that your physician or
the physician’s practice has taken an action in
reliance on the use or disclosure indicated in the
authorization.
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Your Rights
Following is a statement of your rights with respect
to your protected heath information.
You have the right to inspect and copy your protected
heath information.
Under federal law, however, you may not inspect or
copy the following records: psychotherapy notes:
information compiled in reasonable anticipation of, or
use in, a civil, criminal, or administrative action or
proceeding, and protected heath information that is
subject to law that prohibits access to protected
health information.
You have the right to request a restriction of your
protected health information.
This mean you may ask us not to use or disclose any
part of your protected health information for the
purposes of treatment, payment or healthcare
operations. You may also request that any part of
your protected health information may not be disclosed
to family members or friends who may be involved in
your care or for notification purposes as described in
this Notice of Privacy Practices. Your request must
state the specific restriction requested and to whom
you want the restriction to apply.
Your physician is not required to agree to a
restriction that you may request. If physician
believes it is in your best interest to permit use and
disclosure of your protected health information, your
protected health information will not be restricted.
You then have the right to use another Healthcare
Professional.
You have the right to request to receive confidential
communications from us by alternative means or at an
alternative location. You have the right to obtain a
paper copy of this notice from us, upon
request, even if you have agreed to accept this notice
alternatively, i.e. electronically.
You may have the right to have your physician amend
your protected health information. If we deny your
request for amendment, you have the right to file a
statement of disagreement with us and we may prepare a
rebuttal to your statement and will provide you with a
copy of any such rebuttal.
You have the right to receive an accounting of certain
disclosures we have made, if any, of your protected
health information.
We reserve the right to change the terms of this
notice and will inform you by mail of any changes.
You then have the right to object or withdraw as
provided in this notice.
Complaints
You may complain to us or to the Secretary of Health
and Human Services if you believe your privacy rights
have been violated by us. You may file a complaint
with us by notifying our privacy contact of your
complaint.
We will not retaliate against you for filing a
complaint.
This notice was published and
becomes effective on/or before
April 14, 2003.
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We are required by law to maintain the privacy of, and
provide individuals with, this notice of our legal
duties and privacy practices with respect to protected
health information. If you have any objections to
this form, please ask to speak with our HIPAA
Compliance Officer in person or by phone at our Main
Phone Number.
Print Name:
_____________________________________________________
Signature:
_____________________________________________________
Date Signed: _________________________
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