This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
State and Federal laws require us to maintain the privacy of your health information and to inform you about our privacy practices by providing you with this Notice. We must follow the privacy practices as described below. This Notice will take effect on April 15, 2003 and will remain in effect until it is amended or replaced by us.
lt is our right to change our privacy practices provided law permits the changes. Before we make a significant change, this Notice will be amended to reflect the changes and we will make the new Notice available upon request. We reserve the right to make any changes in our privacy practices and the new terms of our Notice effective for all health information maintained, created and/or received by us before the date changes were made.
You may request a copy of our Privacy Notice at any time by contacting our Privacy Officer; information on contacting us can be found at the end of this notice.
TYPICAL USES AND DISCLOSURE OF HEALTH INFORMATION
We will keep your health information confidential, using it only for the following purposes:
Treatment: We may use your health information to provide you with our professional services. We have established "mínimum necessary or need to know" standards that limit various staff members' access to your health information according to their primary job functions. Everyone on our staff is required to sign a confidentiality statement.
Disclosure: We may disclose and/or share your healthcare information with other healthcare professionals who provide treatment and/or service to you. These professionals will have a privacy and confidentiality policy like this one. Health information about you may also be disclosed to your family, friends, and/or other persons you choose to involve in your care, only if you agree that we may do so.
Payment: We may use and disclose your health information to seek payment for services we provide to you. This disclosure involves our business staff and may include insurance organizations or other businesses that may become involved in the process of mailing statements and/or
Emergencies: We may use or disclose your health information to notify, or assist in the notification of a family member or anyone responsible for your care, in case of any emergency involving your care, your location, your general condition or death. lf at all possible we will provide you with an opportunity to object to this use or disclosure.
Healthcare Operations: We will use and disclose your health information to keep our practice operable. Examples of personnel who may have access to this information include, but are not limited to, our medical records staff, outside health or management reviewers and individuals performing similar activities.
Required by Law: We may use or disclose your health information when we are required to do so by law. (Court or administrative orders, subpoena, discovery request or other lawful process.) We will use and disclose your information when requested by national security, intelligence and other State and Federal officials and/or if you are an in mate or otherwise under the custody of law enforcement.
Abuse and Neglect: We may disclose your health information to appropriate authorities if we reasonable believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. This information will be disclosed only to the extent necessary to prevent a serious threat to your health or safety or that of others.
Public Health Responsibilities: We will disclose your healthcare information to report problems with products, reactions to medications, product recalls, disease/infection exposure and to prevent and control disease, injury and/or disability.
Marketing Health-Related Services: We will not use your health information for marketing purposes unless we have your written authorization to do so.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders, including, but not limited to, voicemail messages, postcards or letters.
National Security: The health information of Armed Forces personnel may be disclosed to military authorities under certain circumstances. lf the information is required for lawful intelligence, counterintelligence or other national security, we may disclose it to authorized federal officials.
YOUR PRIVACY RIGHTS AS OUR PATIENT:
Access: Upon written request, you have the right to inspect and get copies of your health information (and that of an individual for whom you are a legal guardian.) There will be some limited exceptions. lf you wish to examine your health information, you will need to complete and submit an appropriate request form.
Amendment: You have the right to amend your healthcare information, if you feel it is inaccurate or incomplete. Your request must be in writing and must include an explanation of why the information should be amended. Under certain circumstances, your request may be denied.
Non-routine Disclosures: you have the right to receive a list of non-routine disclosures we have made of your healthcare information.
Restrictions: You have the right request that we place additional restrictions on our use or disclosure of your health information. This request must be submitted in writing.
QUESTIONS AND COMPLAINTS:
You have the right to file a complaint with us if we feel we have not complied with our Privacy Policies. Your complaint should be directed to our Privacy Officer. We support your right to the privacy of your information and will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
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Document Name: HIPPA Form
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