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This summary is provided to assist you in understanding
the attached Notice of Privacy Practices.
The attached 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 practices in dealing with patient health
information. Please refer to that Notice for further
information.
Uses and Disclosures of Health Information. We will
use and disclose your 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 us 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 not use or disclose your health information
without your written authorization.
Uses and Disclosures Not 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 the law.
Patient Rights. 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 you in 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 attached
Notice of Privacy Practices for the person or persons
whom you may contact.
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. THE PRIVACY OF YOUR MEDICAL
INFORMATION IS IMPORTANT TO US.
Our Legal Duty
We are required by applicable federal and state laws
to maintain the privacy of your protected health information.
We are also required to give you this notice about our
privacy practices, our legal duties, and your rights
concerning your protected health information. We must
follow the privacy practices that are described in this
notice while it is in effect. This notice takes effect
April 14, 2003, and will remain in effect until we replace
it.
We reserve the right to change our privacy practices
and the terms of this notice at any time, provided that
such changes are permitted by applicable law. We reserve
the right to make the changes in our privacy practices
and the new terms of our notice effective for all protected
health information that we maintain, including medical
information we created or received before we made the
changes.You may request a copy of our notice (or any
subsequent revised notice) at any time. For more information
about our privacy practices, or for additional copies
of this notice, please contact us using the information
listed at the end of this notice.
Uses and Disclosures of Protected Health Information
We will use and disclose your protected health information
about you for treatment, payment, and health care operations.
Following are examples of the types of uses and disclosures
of your protected health care information that may occur.
These examples are not meant to be exhaustive, but to
describe the types of uses and disclosures that may
be made by our office.
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. We
will also disclose protected health information to other
physicians who may be treating 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.
In addition, we may disclose your protected health
information from time to time to another physician or
health care provider (e.g., a specialist or laboratory)
who, at the request of your physician, becomes involved
in your care by providing assistance with your health
care diagnosis or treatment to your physician.
Payment: Your protected health information
will be used, as needed, to obtain payment for your
health care services. This may include certain activities
that your health insurance plan may undertake before
it approves or pays for the health care services we
recommend for you, such as: making a determination of
eligibility or coverage for insurance benefits, reviewing
services provided to you for protected health necessity,
and undertaking utilization review activities. 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.
Health Care Operations: We may use
or disclose, as needed, your protected health information
in order to conduct certain business and operational
activities. These activities include, but are not limited
to, quality assessment activities, employee review activities,
training of students, licensing, and conducting or arranging
for other business activities. For example, we may use
a sign-in sheet at the registration desk where you will
be asked to sign your name. We may also call you by
name in the waiting room when your doctor is ready to
see you. We may use or disclose your protected health
information, as necessary, to contact you by telephone
or mail to remind you of your appointment. If you desire
not to be contacted, please let us know.
We will share your protected health information with
third party "business associates" that perform
various activities (e.g., billing, transcription services)
for the practice. Whenever an arrangement between our
office and a business associate involves the use or
disclosure of your protected health information, we
will have a written contract that contains terms that
will protect the privacy of your protected health information.
We may use or disclose your protected health information,
as necessary, to provide you with information about
treatment alternatives or other health-related benefits
and services that may be of interest to you. We may
also use and disclose your protected health information
for other marketing activities. For example, your name
and address may be used to send you a newsletter about
our practice and the services we offer. We may also
send you information about products or services that
we believe may be beneficial to you. You may contact
us to request that these materials not be sent to you.
Uses and Disclosures Based On Your Written
Authorization: Other uses and disclosures of
your protected health information will be made only
with your authorization, unless otherwise permitted
or required by law as described below.
You may give us written authorization to use your protected
health information or to disclose it to anyone for any
purpose. If you give us an authorization, you may revoke
it in writing at any time. Your revocation will not
affect any use or disclosures permitted by your authorization
while it was in effect. Without your written authorization,
we will not disclose your health care information except
as described in this notice.
Others Involved in Your Health Care:
Unless you object, we may disclose to a member of your
family, a relative, a close friend or any other person
you identify, your protected health information that
directly relates to that person's involvement in your
health care. If you are unable to agree or object to
such a disclosure, we may disclose such information
as necessary if we determine that it is in your best
interest based on our professional judgment. 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.
Marketing: We may use your protected
health information to contact you with information about
treatment alternatives that may be of interest to you.
We may disclose your protected health information to
a business associate to assist us in these activities.
Unless the information is provided to you by a general
newsletter or in person or is for products or services
of nominal value, you may opt out of receiving further
such information by telling us using the contact information
listed at the end of this notice.
Research; Death; Organ Donation: We
may use or disclose your protected health information
for research purposes in limited circumstances. We may
disclose the protected health information of a deceased
person to a coroner, protected health examiner, funeral
director or organ procurement organization for certain
purposes.
Public Health and Safety: We may disclose
your protected health information to the extent necessary
to avert a serious and imminent threat to your health
or safety, or the health or safety of others. We may
disclose your protected health information to a government
agency authorized to oversee the health care system
or government programs or its contractors, and to public
health authorities for public health purposes.
Health Oversight: We may disclose
protected health information to a health oversight agency
for activities authorized by law, such as audits, investigations
and inspections. Oversight agencies seeking this information
include government agencies that oversee the health
care system, government benefit programs, other government
regulatory programs and civil rights laws.
Abuse or Neglect: We may disclose
your protected health information to a public health
authority that is authorized by law to receive reports
of child abuse or neglect. In addition, we may disclose
your protected health information if we believe that
you have been a victim of abuse, neglect or domestic
violence to the governmental entity or agency authorized
to receive such information. In this case, the disclosure
will be made consistent with the requirements of applicable
federal and state laws.
Food and Drug Administration: We may
disclose your protected health information to a person
or company required by the Food and Drug Administration
to report adverse events, product defects or problems,
biologic product deviations; to track products; to enable
product recalls; to make repairs or replacements; or
to conduct post marketing surveillance, as required.
Criminal Activity: Consistent with
applicable federal and state laws, we may disclose your
protected health information, if we believe that the
use or disclosure is necessary to prevent or lessen
a serious and imminent threat to the health or safety
of a person or the public. We may also disclose protected
health information if it is necessary for law enforcement
authorities to identify or apprehend an individual.
Required by Law: We may use or disclose
your protected health information when we are required
to do so by law. For example, we must disclose your
protected health information to the U.S. Department
of Health and Human Services upon request for purposes
of determining whether we are in compliance with federal
privacy laws. We may disclose your protected health
information when authorized by workers' compensation
or similar laws.
Process and Proceedings: We may disclose
your protected health information in response to a court
or administrative order, subpoena, discovery request
or other lawful process, under certain circumstances.
Under limited circumstances, such as a court order,
warrant or grand jury subpoena, we may disclose your
protected health information to law enforcement officials.
Law Enforcement: We may disclose limited
information to a law enforcement official concerning
the protected health information of a suspect, fugitive,
material witness, crime victim or missing person. We
may disclose the protected health information of an
inmate or other person in lawful custody to a law enforcement
official or correctional institution under certain circumstances.
We may disclose protected health information where necessary
to assist law enforcement officials to capture an individual
who has admitted to participation in a crime or has
escaped from lawful custody.
Access: You have the right to look
at or get copies of your protected health information,
with limited exceptions. You must make a request in
writing to the contact person listed herein to obtain
access to your protected health information. You may
also request access by sending us a letter to the address
at the end of this notice. If you request copies, we
will chargeyou $.10 for each page, $10.00 per hour for
staff time to locate and copy your protected health
information, and postage if you want the copies mailed
to you. If you prefer, we will prepare a summary or
an explanation of your protected health information
for a fee. Contact us using the information listed at
the end of this notice for a full explanation of our
fee structure.
Accounting of Disclosures: You have
the right to receive a list of instances in which we
or our business associates disclosed your protected
health information for purposes other than treatment,
payment, health care operations and certain other activities
after April 14, 2003. After April 14, 2009, the accounting
will be provided for the past six (6) years. We will
provide you with the date on which we made the disclosure,
the name of the person or entity to whom we disclosed
your protected health information, a description of
the protected health information we disclosed, the reason
for the disclosure, and certain other information. If
you request this list more than once in a 12-month period,
we may charge you a reasonable, cost-based fee for responding
to these additional requests. Contact us using the information
listed at the end of this notice for a full explanation
of our fee structure.
Restriction Requests: You have the
right to request that we place additional restrictions
on our use or disclosure of your protected health information.
We are not required to agree to these additional restrictions,
but if we do, we will abide by our agreement (except
in an emergency). Any agreement we may make to a request
for additional restrictions must be in writing signed
by a person authorized to make such an agreement on
our behalf. We will not be bound unless our agreement
is so memorialized in writing.
Confidential Communication: You have
the right to request that we communicate with you in
confidence about your protected health information by
alternative means or to an alternative location. You
must make your request in writing. We must accommodate
your request if it is reasonable, specifies the alternative
means or location, and continues to permit us to bill
and collect payment from you.
Amendment: You have the right to request
that we amend your protected health information. Your
request must be in writing, and it must explain why
the information should be amended. We may deny your
request if we did not create the information you want
amended or for certain other reasons. If we deny your
request, we will provide you a written explanation.
You may respond with a statement of disagreement to
be appended to the information you wanted amended. If
we accept your request to amend the information, we
will make reasonable efforts to inform others, including
people or entities you name, of the amendment and to
include the changes in any future disclosures of that
information.
Electronic Notice: If you receive
this notice on our website or by electronic mail (e-mail),
you are entitled to receive this notice in written form.
Please contact us using the information listed at the
end of this notice to obtain this notice in written
form.
If you want more information about our privacy practices
or have questions or concerns, please contact us using
the information below.
If you believe that we may have violated your privacy
rights, or you disagree with a decision we made about
access to your protected health information or in response
to a request you made, you may complain to us using
the contact information published on this web site.
You also may submit a written complaint to the U.S.
Department of Health and Human Services. We will provide
you with the address to file your complaint with the
U.S. Department of Health and Human Services upon request.
We support your right to protect the privacy of your
protected health information. We 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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