Privacy Notice
HIPPA 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. PLEASE REVIEW IT CAREFULLY.
THIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW WE MAY USE AND DISCLOSE YOU PROTECTED HEALTH INFORMATION (PHI) TO CARRY OUT TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS (TPO) AND FOR OTHER PURPOSES THAT ARE PERMITTED OR REQUIRED BY LAW. IT ALSO DESCRIBES YOUR RIGHTS TO ACCESS AND CONTROL YOUR PROTECTED HEALTH INFORMATION, THAT MAY IDENTIFY YOU AND THAT RELATES TO YOUR PAST, PRESENT OR FUTURE PHYSICAL OR MENTAL HEALTH OR CONDITION AND RELATED HEALTH CARE SERVICES.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION.
YOUR PROTECTED HEALTH INFORMATION MAY BE USED AND DISCLOSED BY YOUR PHYSICIAN, OUR OFFICE STAFF AND OTHERS OUTSIDE OF 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 PHYSICIANS 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 OR ANY RELATED SERVICES. THIS INCLUDES THE COORDINATION OR MANAGEMENT OF SERVICES WITH A THIRD PARTY. FOR EXAMPLE WE WILL 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 INSURE 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 HEALTHCARE SERVICES. FOR EXAMPLE, OBTAINING APPROVAL FOR YOUR HOSPITAL STAY MAY REQUIRE THAT YOUR RELEVANT PROTECTED HEALTH INFORMATION BE DISCLOSED TO THE HEALTH PLAN TO OBTAIN APPROVAL FOR THE HOSPITAL ADMISSION.
HEALTHCARE OPERATION: WE MAY USE OR DISCLOSE, AS NEEDED, YOUR PROTECTED HEALTH INFORMATION IN ORDER TO SUPPORT THE BUSINESS ACTIVITIES OF YOUR PHYSICIANS PRACTICE. THESE ACTIVITIES ARE NOT LIMITED AND MAY INCLUDE QUALITY ASSESSMENT ACTIVITIES, EMPLOYEE REVIEW ACTIVITY, TRAINING OF MEDICAL STUDENT, LICENSING OR ARRANGING FOR OTHER BUSINESS ACTIVITIES. FOR EXAMPLE WE MAY DISCLOSE YOUR PROTECTED HEALTH INFORMATION TO MEDICAL 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 WHEN 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 AN APPOINTMENT.
WE MAY USE OR DISCLOSE YOUR PROTECTED INFORMATION I THE FOLLOWING SITUATION WITHOUT YOU AUTHORIZATION. THESE SITUATIONS INCLUDE : AS REQUIRED BY LAW, PUBLIC HEALTH ISSUES REQUITED 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 USE AND DISCLOSURE: UNDER THE LAW, WE MUST MAKE THE 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 YOU CONSENT, AUTHORIZATION OR OPPORTUNITY TO OBJECT REQUIRED BY LAW.
YOU MAY REVOKE THIS AUTHORIZATION, AT ANY TIME IN WRITING, EXCEPT TO THE EXTENT THAT YOUR PHYSICIAN OR PHYSICIAN'S PRACTICE HAS TAKEN AN ACTION IN RELIANCE ON THE USE OF DISCLOSURE INDICATED IN THE AUTHORIZATION.
YOUR RIGHTS: FOLLOWING IS A STATEMENT OF YOUR RIGHTS WITH RESPECT TO YOUR PROTECTED HEALTH INFORMATION.
YOU HAVE TH RIGHT TO INSPECT AND COPY YOUR PROTECTED 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 PROCEEDING,AND PROTECTED HEALTH INFORMATION THAT IS SUBJECT TO THE LAW THAT PROHIBITS ACCESS TO PROTECTED HEALTH INFORMATION.
YOU HAVE THE RIGHT TO REQUEST A RESTRICTION OF YOU PROTECTED HEALTH INFORMATION. THIS MEANS YOU MAY ASK US NOT TO USE OR DISCLOSE ANY PART OF YOUR PROTECTED HEALTH INFORMATION FOR THE PURPOSE OF TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS. YOU MAY ALSO REQUEST THAT ANY PART OF YOUR PROTECTED HEALTH INFORMATION NOT BE DISCLOSED TO FAMILY MEMBERS OR FRIENDS WHO AMY BE INVOLVED IN YOUR CARE OR FOR THE NOTIFICATION PURPOSES AS DESCRIBED IN THIS NOTICE OF PRIVACY PRACTICES. YOUR REQUEST MYST 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 A PHYSICIAN BELIEVES IT IS IN YOUR BEST INTEREST TO PERMIT USE AND DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION , YOUR PROTECTED HEALTH INFORMATION WILL 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 RECEIVE 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 YOU 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 THE PROTECTED, HEALTH INFORMATION.
YOU RESERVE THE RIGHT TO RECEIVE AN ACCOUNTING OF CERTAIN DISCLOSURES WE HAVE MADE, IN 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
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 AS TO SPEAK TO OUR HIPPA COMPLIANCE OFFICES IN PERSON OR BY PHONE AT OUR MAIN NUMBER 631-642-8422.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
THIS NOTICE OF PRIVACY PRACTICES DESCRIBES HOW WE MAY USE AND DISCLOSE YOU PROTECTED HEALTH INFORMATION (PHI) TO CARRY OUT TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS (TPO) AND FOR OTHER PURPOSES THAT ARE PERMITTED OR REQUIRED BY LAW. IT ALSO DESCRIBES YOUR RIGHTS TO ACCESS AND CONTROL YOUR PROTECTED HEALTH INFORMATION, THAT MAY IDENTIFY YOU AND THAT RELATES TO YOUR PAST, PRESENT OR FUTURE PHYSICAL OR MENTAL HEALTH OR CONDITION AND RELATED HEALTH CARE SERVICES.
USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION.
YOUR PROTECTED HEALTH INFORMATION MAY BE USED AND DISCLOSED BY YOUR PHYSICIAN, OUR OFFICE STAFF AND OTHERS OUTSIDE OF 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 PHYSICIANS 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 OR ANY RELATED SERVICES. THIS INCLUDES THE COORDINATION OR MANAGEMENT OF SERVICES WITH A THIRD PARTY. FOR EXAMPLE WE WILL 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 INSURE 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 HEALTHCARE SERVICES. FOR EXAMPLE, OBTAINING APPROVAL FOR YOUR HOSPITAL STAY MAY REQUIRE THAT YOUR RELEVANT PROTECTED HEALTH INFORMATION BE DISCLOSED TO THE HEALTH PLAN TO OBTAIN APPROVAL FOR THE HOSPITAL ADMISSION.
HEALTHCARE OPERATION: WE MAY USE OR DISCLOSE, AS NEEDED, YOUR PROTECTED HEALTH INFORMATION IN ORDER TO SUPPORT THE BUSINESS ACTIVITIES OF YOUR PHYSICIANS PRACTICE. THESE ACTIVITIES ARE NOT LIMITED AND MAY INCLUDE QUALITY ASSESSMENT ACTIVITIES, EMPLOYEE REVIEW ACTIVITY, TRAINING OF MEDICAL STUDENT, LICENSING OR ARRANGING FOR OTHER BUSINESS ACTIVITIES. FOR EXAMPLE WE MAY DISCLOSE YOUR PROTECTED HEALTH INFORMATION TO MEDICAL 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 WHEN 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 AN APPOINTMENT.
WE MAY USE OR DISCLOSE YOUR PROTECTED INFORMATION I THE FOLLOWING SITUATION WITHOUT YOU AUTHORIZATION. THESE SITUATIONS INCLUDE : AS REQUIRED BY LAW, PUBLIC HEALTH ISSUES REQUITED 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 USE AND DISCLOSURE: UNDER THE LAW, WE MUST MAKE THE 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 YOU CONSENT, AUTHORIZATION OR OPPORTUNITY TO OBJECT REQUIRED BY LAW.
YOU MAY REVOKE THIS AUTHORIZATION, AT ANY TIME IN WRITING, EXCEPT TO THE EXTENT THAT YOUR PHYSICIAN OR PHYSICIAN'S PRACTICE HAS TAKEN AN ACTION IN RELIANCE ON THE USE OF DISCLOSURE INDICATED IN THE AUTHORIZATION.
YOUR RIGHTS: FOLLOWING IS A STATEMENT OF YOUR RIGHTS WITH RESPECT TO YOUR PROTECTED HEALTH INFORMATION.
YOU HAVE TH RIGHT TO INSPECT AND COPY YOUR PROTECTED 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 PROCEEDING,AND PROTECTED HEALTH INFORMATION THAT IS SUBJECT TO THE LAW THAT PROHIBITS ACCESS TO PROTECTED HEALTH INFORMATION.
YOU HAVE THE RIGHT TO REQUEST A RESTRICTION OF YOU PROTECTED HEALTH INFORMATION. THIS MEANS YOU MAY ASK US NOT TO USE OR DISCLOSE ANY PART OF YOUR PROTECTED HEALTH INFORMATION FOR THE PURPOSE OF TREATMENT, PAYMENT OR HEALTHCARE OPERATIONS. YOU MAY ALSO REQUEST THAT ANY PART OF YOUR PROTECTED HEALTH INFORMATION NOT BE DISCLOSED TO FAMILY MEMBERS OR FRIENDS WHO AMY BE INVOLVED IN YOUR CARE OR FOR THE NOTIFICATION PURPOSES AS DESCRIBED IN THIS NOTICE OF PRIVACY PRACTICES. YOUR REQUEST MYST 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 A PHYSICIAN BELIEVES IT IS IN YOUR BEST INTEREST TO PERMIT USE AND DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION , YOUR PROTECTED HEALTH INFORMATION WILL 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 RECEIVE 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 YOU 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 THE PROTECTED, HEALTH INFORMATION.
YOU RESERVE THE RIGHT TO RECEIVE AN ACCOUNTING OF CERTAIN DISCLOSURES WE HAVE MADE, IN 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
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 AS TO SPEAK TO OUR HIPPA COMPLIANCE OFFICES IN PERSON OR BY PHONE AT OUR MAIN NUMBER 631-642-8422.