NOTICE OF PRIVACY PRACTICES
The Notice of Privacy Practices describes how this practice may use and disclose your medical
information, as well as your rights to access your medical information. If you still have questions, after
reading this document, please contact our office HIPAA Privacy Officer.
The HIPAA Privacy Rule permits this practice to disclose your protected health information to carry out
Treatment, Payment, or other Healthcare Operations. We may also disclose your health information for
purposes required by law. HIPAA also grants you rights to access and control your protected health
information. We must abide by the information outlined in the Notice of Privacy Practices. As HIPAA
evolves, we reserve the right to update our Notice of Privacy Practices at any time. You also have the
right to request a copy of our current Notice of Privacy Practices at any time.
USES AND DISCLOSURES
Your protected health information may be used and disclosed by your physician, our office staff and
others who are involved in your care and treatment for treatment, payment, or other healthcare operations.
The following are common types of uses and disclosures your physician’s office is authorized to make.
While not a complete list of allowable disclosures, these examples will provide you with an
understanding of acceptable disclosures made by this practice.
Treatment: Our practice will use and disclose your protected health information to provide, coordinate,
or manage your health care. This includes the coordination or management of your health care with
another provider. We will disclose protected health information to any other physicians who may be
treating you. We may also disclose your protected health information to another physician or health care
provider, such as a laboratory, who becomes involved in your treatment.
Health Care Operations: Our practice will use and disclose your protected health information in order
to support our practice’s business activities. Examples of health care operations include, but are not
limited to, quality assessment, employee reviews, medical student training, licensing, fundraising, and
conducting or arranging for other business activities. We may also provide you with information about
treatment alternatives or other services that may be of interest to you. Please contact our Privacy Officer if
you would prefer these materials not be sent to you.
We may use or disclose your demographic information and the dates that you received treatment from
your physician, in order to contact you for fundraising activities supported by our practice. Please contact
our practice Privacy Officer if you do not wish to receive these materials.
Payment: Our practice will use and disclose your protected health information, to obtain payment for
your services performed by us or by another provider. This may include disclosures to health insurance
plans, insurance providers, and collection agencies. We strongly encourage you to be in contact with your
insurance agency to determine the level of coverage your plan provides, as well as having an
understanding of the financial figures you will be responsible for.
Business Associates: We will share your protected health information with third party “business
associates” that perform various activities on our behalf. Examples of a Business Associate include,
billing services, transcription services, and legal services. Prior to disclosing any protected health
information with a business associate, we will establish a written contract that contains the terms that will
protect the privacy of your information. Business Associates and their subcontractors must also comply
with HIPAA Privacy and Security Regulations. We verify their understanding and responsibility.
Patient Packet Rev 04/14/2015
Provided by Compliance PhD
HIPAA Permits and Requires Additional Uses and Disclosures That May Be Made Without Your
Authorization or Opportunity to Agree or Object. These situations include:
Disclosures Required By Law & Workers Compensation: We are permitted to use or disclose your
protected health information to the extent that law requires the use or disclosure. We will maintain
compliance with the law and will limit the disclosure to the minimum necessary. If required, you will be
notified of any disclosure. We are permitted to disclose your protected health information as authorized to
comply with workers’ compensation laws and other similar legally established programs.
Abuse or Neglect: We believe abuse or neglect to be a serious issue. We may disclose your protected
health information to a public health authority authorized to receive reports of child abuse or neglect. We
may also disclose your information if, in our best judgment, we believe you have been a victim of abuse,
neglect or domestic violence. When disclosing protected health information in cases of abuse or neglect,
we will follow applicable state and federal laws.
Public Health & Communicable Diseases: We are permitted to disclose your protected health
information for public health purposes or to a public health authority that is permitted by law to collect or
receive the information. Examples may include disclosure to prevent or controlling disease, or injury. We
are permitted to disclose your protected health information, if authorized by law, to a person who may
have been exposed to a communicable disease. We may disclose your information if said person may be
at risk of contracting or spreading the disease or condition.
Research & Health Oversight: We are permitted to disclose your protected health information to
researchers when an institutional review board that has reviewed the research proposal, as well as
established protocols to ensure the privacy of your information has approved their research. We are
permitted to disclose protected health information to a health oversight agency for activities authorized by
law, such as audits, investigations, and inspections.
Legal Proceedings: We are permitted to disclose protected health information in connection with any
judicial or administrative proceeding, subpoena, or in responding to a court order or tribunal.
Law Enforcement: We may also disclose protected health information, under lawful conditions to law
enforcement. Permitted law enforcement purposes include (1) legal processes and otherwise required by
law, (2) limited information requests for identification and location purposes, (3) pertaining to victims of
a crime, (4) suspicion that death has occurred as a result of criminal conduct, (5) in the event that a crime
occurs on the premises of our practice, and (6) medical emergency associated with a crime.
Organ Donation, Coroners, & Funeral Directors: We are permitted to disclose protected health
information to a coroner or medical examiner for identification purposes, determining cause of death or
for the coroner or medical examiner to perform other duties. Disclose may be made in reasonable
anticipation of death. Protected health information may be used and disclosed for cadaveric organ, eye or
tissue donation purposes.
Military Activity and National Security: We are permitted to use or disclose protected health
information of individuals who are Armed Forces personnel under the following circumstances: (1) for
activities deemed necessary by appropriate military command authorities; (2) for the purpose of a
determination by the Department of Veterans Affairs of your eligibility for benefits, or (3) to foreign
military authority if you are a member of that foreign military services. We are also permitted to disclose
your information to authorized federal officials for conducting national security and intelligence
activities, including for the provision of protective services to the President or others legally authorized.
Patient Packet Rev 04/14/2015
Provided by Compliance PhD
Unless required by law, your written authorization will be required for all other uses and disclosures of
your protected health information. You may revoke authorization at any time, by written request. If you
revoke your authorization, we will no longer use or disclose your protected health information for the
reasons covered by your written authorization. Note: We are unable to undo any disclosures previously
made with your authorization.
Opportunity to Agree or Object
The following are examples of instances where we may use and disclose your protected health
information; however, you have the opportunity to agree or object to the use or disclosure of all or part of
the disclosure. If you are not present or able to agree or object to the use or disclosure, then we may,
using professional judgment, determine whether the disclosure is in your best interest.
• Unless you object, we may disclose to a member of your family, a relative, or a close friend, your
protected health information that directly relates to that person’s involvement in your health care. We
may use or disclose protected health information to notify or assist in notifying a family member,
personal representative or any other person that is responsible for your care of your location, general
condition or death. Finally, we may use or disclose your information to an authorized public or
private entity to assist in disaster relief efforts and to coordinate uses and disclosures to family or
other individuals involved in your care.
• Unless you object, we will use and disclose in our facility directory your name, the location at which
you are receiving care, your general condition, and your religious affiliation. This information,
except religious affiliation, will be disclosed to individuals who ask for you by name. Your religious
affiliation will be only given to a member of the clergy, such as a priest or rabbi.
• Should we chose to participate in Marketing or Fundraising Efforts we will first provide you with an
opportunity to Opt-Out of such Marketing or Fundraising Materials. You will be made aware if our Marketing
or Fundraising Efforts will include our practice receiving financial remuneration. You will have the opportunity
to opt-our of our current marketing or fundraising efforts, or to opt-out of all future marketing or fundraising
efforts. Because we may receive financial remuneration, you will be provided with a separate form to authorize
or opt-out of our efforts.
You have the right to inspect and copy your protected health information. As long as we are
maintaining your protected health information, you may inspect and obtain a copy of your protected
health information. You may obtain your medical record that contains medical and billing records and
any other records that your physician uses for health care decisions. As permitted by federal or state law,
we may charge you a “reasonable copy fee” for a copy of your records.
However, federal law prohibits you from inspecting or copying: psychotherapy notes; information
compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding;
and laboratory results that are subject to law that prohibits access. You may have the right to appeal the
denial. Please contact our Privacy Officer if you have questions.
You have the right to request a restriction of your protected health information. You may ask us not
to use or disclose any part of your protected health information 1) for the purposes of treatment,
healthcare operations, or payment 2) to family members or friends who may be involved in your care or
Patient Packet Rev 04/14/2015
Provided by Compliance PhD
3) for notification purposes as described in this Notice of Privacy Practices. Your written request must
state the specific restriction requested and to whom you want the restriction to apply. We are NOT
required to agree to a restriction that you may request, unless your account has been paid in full.
However, if your physician does agree to the requested restriction, we may not use or disclose your
protected health information in violation of that restriction other than emergency treatment situations.
You have the right to request to receive confidential communications from us by alternative means
or at an alternative location. We strive to accommodate all reasonable requests. As a condition, we may
ask for additional information, such as payment, alternative address, or additional contact information.
We will not request an explanation for the request. Notify our Privacy Officer in writing for all requests.
You have the right to receive an accounting of certain disclosures made. This right applies to
disclosures for purposes other than treatment, payment or health care operations as described in this
Notice of Privacy Practices. It excludes disclosures we may have made to you if you authorized us to
make the disclosure, for a facility directory, to family members or friends involved in your care, or for
notification purposes, for national security or intelligence, to law enforcement or correctional facilities, as
part of a limited data set disclosure. You have the right to receive specific information regarding these
disclosures that occur after April 14, 2003. The right to receive this information is subject to certain
exceptions, restrictions and limitations.
You may request an amendment of your protected health information in a designated record set for
so long as we maintain this information. We may deny your request for an amendment. If we deny
your request for amendment, you have the right to file a statement of disagreement and we may provide
you with a copy of any rebuttal. Please contact our Privacy Officer if you have questions.
If we maintain an electronic copy of your Medical Records then you have the right to receive an
electronic copy of your Medical Records.
You have the right to obtain a hard copy of this Notice of Privacy Practices.
Should you believe your privacy rights have been violated, and you wish to file a complaint, you may
complain to us or to the Secretary of Health and Human Services.
To file a Complaint with us, you may contact our Privacy Officer. Protecting your private health
information is essential to us, and we will not retaliate against you should you file a complaint.
Complaints filed with the Secretary of Health and Human Services should be directed to your regional
office. A directory of regional offices can be found by visiting the following website: