Notice of Privacy Practices for Protected Health Information

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.  You have the right to the confidentiality of your medical information, and this practice is required by law to maintain the privacy of that protected health information.  This practice is required to abide by the terms of the Notice of Privacy Practices currently in effect, and to provide notice of its legal duties and privacy practices with respect to protected health information.  If you have any questions about this Notice, please contact our Receptionist.

Who Will Follow This Notice

Any health care professional authorized to enter information into your medical record, all employees, staff and other personnel at this practice who may need access to you information must abide by this Notice.  All subsidiaries, business associates (e.g. a billing service), sites and locations of this practice may share medical information with each other for treatment, payment purposes or health care operations described in this Notice.  

How We May Use and Disclose Medical Information About You

The following categories are different ways that we may use and disclose medical information without your specific consent or authorization.  Not every possible use or disclosure in a category is listed.

-For treatment:  In treating you for a specific condition, we may need to know if you have allergies that could influence which medications we prescribe for the treatment process.

-For payment:  We may need to send your protected health information, such as your name, address, office visit date, and codes identifying your diagnosis and treatment to you insurance company for payment.

-For health care operation:  We may use medical information to review our treatment and services and evaluate the performance of our staff in caring for you.

Other uses and disclosures of medical information not covered by this Notice or the laws that apply to us will be made only with your written authorization.  If you give us authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any times.  If you revoke your authorization, we will thereafter no longer use or disclose medical information about you for the reasons covered by your written authorization.  You understand that we are unable to take back any disclosures we have already made with your authorization, and that we are required to retain our records of the care we have provided you.


Your Individual Rights Regarding Your Medical Information

-Complaints.  If you believe your privacy rights have been violated, you may file a complaint with the receptionist at our practice or with the Secretary of the Department of Health and Human Services.  All complaints must be submitted in writing.

-Right to Request Restrictions.  You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations or to someone who is involved in your care or the payment for you care.  We are not required to agree to you request.  If we do agree, we will comply with your request unless the information is needed to provide you with emergency treatment.

-Right to Request Confidential Communications.  You have the right to request how we should send communications to you about medical matters, and where you would like those communications sent.  We will not ask you the reason for your request.  We will accommodate all reasonable requests.  You must specify how or where you wish to be contacted. We reserve the right to deny a request if it imposes an unreasonable burden on the practice.

-Right to Inspect and Copy.  You have the right to inspect and copy medical information that may be used to make decisions about your care.  Usually this includes medical and billing records but does not include psychotherapy notes, information compiled for use in a civil, criminal, or administrative action or proceeding, and protected health information to which access is prohibited by law.  We reserve the right to charge a fee for the costs of copying, mailing or other supplies associated with your request.  If you are denied access to medical information, you may request that the denial be reviewed.  Another licensed health care professional chosen by this practice will review you request and the denial.  We will comply with the outcome of the review.

-Right to Amend.  If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information.  You have the right to request an amendment for as long as the information is kept.  You must provide a reason that supports you request.  If we deny you request for amendment, you have the right to file a statement of disagreement with us.  We may prepare a rebuttal to you statement and provide you with a copy of any such rebuttal.  Statements of disagreement and any corresponding rebuttals will be kept on file.

-Right to an Accounting of Non-Standard Disclosures.  You have the right to request a list of the disclosures we made of medical information about you.  Your request must state the time period for which you want to receive a list of disclosures that is no longer than six years.  The first list you request within a 12-month period is free.  For additional lists, we reserve the right to charge you for the cost of providing the list.

-Right to a Paper Copy of This Notice.  You have the right to a paper copy of our current Notice of Privacy Practices at any time.   Even if you have agreed to receive this Notice electronically, you are still entitled to a paper copy.


We reserve the right to change this Notice.  We reserve the right to make the revised or changed Notice effective for medical information we already have about you as well as any information we receive in the future.