Office: New Patient Forms
Notice of Privacy Practices (Medical)
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 Health Insurance Portability & Accountability Act of 1996 (“HIPAA”)
is a federal program that requires that all medical records and other individually
identifiable health information used or disclosed by us in any form, whether
electronically, on paper, or orally, are kept properly confidential. This Act
gives you, the patient significant new rights to understand and control how your
health information is used. “HIPAA” provides penalties for covered
entities that misuse personal health information.
As required by “HIPAA”, we have prepared this explanation of how
we are required to maintain the privacy of your health information and how we
may use and disclose your health information.
We may use and disclose your medical records
only for each of the following purposes: treatment,
payment and health care operations.
- Treatment means providing, coordinating,
or managing health care and related
services by one or more health care providers. An example of this would
- Payment means such activities
as obtaining reimbursement for services, confirming
coverage, billing or collection activities,
and utilization review. An example of this
would be sending a bill for your visit to your
insurance company for payment.
- Health care operations include
the business aspects of running our practice, such as conducting
quality assessment and improvement activities,
auditing functions, cost-management analysis,
and customer service. An example would be
an internal quality assessment review.
We may also create and distribute de-identified
health information by removing all references
to individually identifiable information.
We may contact you to provide appointment reminders
or information about treatment alternatives or
other health-related benefits and services that
may be of interest to you.
Any other uses and disclosures will be made
only with your written authorization. You may
revoke such authorization in writing and we are
required to honor and abide by that written request,
except to the extent that we have already taken
actions relying on your authorization.
You have the following rights with respect
to your protected health information, which you
can exercise by presenting a written request
to the Privacy Officer:
· The right to request restrictions on certain
uses and disclosures of protected health information,
including those related to disclosures to family
members, other relatives, close personal friends,
or any other person identified by you. We are,
however, not required to agree to a requested restriction.
If we do agree to a restriction, we must abide
by it unless you agree in writing to remove it.
- The right to reasonable requests to
receive confidential communications of protected
health information from us by alternative means
or at alternative locations.
- The right to inspect and copy your
protected health information.
- The right to amend your protected health
- The right to receive an accounting
of disclosures of protected health information.
- The right to obtain a paper copy of
this notice from us upon request.
We are required by law to maintain the privacy
of your protected health information and to
provide you with notice of our legal duties
and privacy practices with respect to protected
This notice is effective as of ___________________,
20____ and we are required to abide by the terms
of the Notice of Privacy Practices currently
in effect. We reserve the right to change the
terms of our Notice of Privacy Practices and
to make the new notice provisions effective for
all protected health information that we maintain.
We will post and you may request a written copy
of a revised Notice of Privacy Practices from
You have recourse if you feel that your privacy
protections have been violated. You have the
right to file written complaint with our office,
or with the Department of Health & Human
Services, Office of Civil Rights, about violations
of the provisions of this notice or the policies
and procedures of our office. We will not retaliate
against you for filing a complaint.
Please contact us for more information: For
more information about HIPAA
Or to file a complaint:
The U.S. Department of Health & Human
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
Toll Free: 1-877-696-6775
Here for a Printable Downloadable PDF of