THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
This Practice is committed to maintaining the privacy of your protected health information (“PHI”), which includes information about your health condition and the care and treatment you receive from the Practice. The creation of a record detailing the care and services you receive helps this office to provide you with quality health care. This Notice details how your PHI may be used and disclosed to third parties. This Notice also details your rights regarding your PHI. The privacy of PHI in patient files will be protected when the files are taken to and from the Practice by placing the files in a box or brief case and kept within the custody of a doctor or employee of the Practice authorized to remove the files from the Practice’s office.
NO CONSENT REQUIRED
The Practice may use and/or disclose your PHI for the purposes of:
The Practice may use and/or disclose your PHI, without a written Consent from you, in the following additional instances:
Your health care provider or a staff member may disclose your health information to contact you to provide appointment reminders. If you are not at home to receive an appointment reminder, a message will be left on your answering machine, voice mail, or with the person who answers the call. You have the right to refuse us authorization to contact you to provide appointment reminders. If you refuse us authorization, it will not affect the treatment we provide to you.
The Practice may disclose to your family member, other relative, a close personal friend, or any other person identified by you, your PHI directly relevant to such person’s involvement with your care or the payment for your care unless you direct the Practice to the contrary. The Practice may also use or disclose your PHI to notify or assist in the notification (including identifying or locating) a family member, a personal representative, or another person responsible for your care, of your location, general condition or death. However, in both cases, the following conditions will apply:
Uses and/or disclosures, other than those described above, will be made only with your written Authorization.
Your Right to Revoke Your Authorization
You may revoke your authorization to us at any time; however, your revocation must be in writing.
You may request restrictions on certain use and/or disclosure of your PHI as provided by law. However, the Practice is not obligated to agree to any requested restrictions. To request restrictions, you must submit a written request to the Practice’s Privacy Officer. In your written request, you must inform the Practice of what information you want to limit, whether you want to limit the Practice’s use or disclosure, or both, and to whom you want the limits to apply. If the Practice agrees to your request, the Practice will comply with your request unless the information is needed in order to provide you with emergency treatment.
You Have a Right to
Inspect and obtain a copy your PHI as provided by 45 CFR 164.524. To inspect and copy your PHI, you are requested to submit a written request to the Practice’s Privacy Officer. The Practice can charge you a fee for the cost of copying, mailing or other supplies associated with your request.
Receive confidential communications or PHI by alternative means or at alternative locations. You must make your request in writing to the Practice’s Privacy Officer. The Practice will accommodate all reasonable requests.
Prohibit report of any test, examination or treatment to your health plan or anyone else for which you pay in cash or by credit card.
Receive an accounting of disclosures of your PHI as provided by 45 CFR 164.528. The request should indicate in what form you want the list (such as a paper or electronic copy).
Receive a paper copy of this Privacy Notice from the Practice upon request to the Practice’s Privacy Officer or request copies of your PHI in electronic format if this office maintains your records in that format.
Amend your PHI as provided by 45 CFR 164.528. To request an amendment, you must submit a written request to the Practice’s Privacy Officer. You must provide a reason that supports your request. The Practice may deny your request if it is not in writing, if you do not provide a reason in support of your request, if the information to be amended was not created by the Practice (unless the individual or entity that created the information is no longer available), if the information is not part of your PHI maintained by the Practice, if the information is not part of the information you would be permitted to inspect and copy, and/or if the information is accurate and complete. If you disagree with the Practice’s denial, you will have the right to submit a written statement of disagreement.
Receive notice of any breach of confidentiality of your PHI by the Practice.
Complain to the Practice or to the Office of Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, HHH Building, Washington, D.C. 20201, 202 619-0257, email: email@example.com if you believe your privacy rights have been violated. To file a complaint with the Practice, you must contact the Practice’s Privacy Officer. All complaints must be in writing.
The Practice is required by federal law to maintain the privacy of your PHI and to provide you with this Privacy Notice detailing the Practice’s legal duties and privacy practices with respect to your PHI; is required to abide by the terms of this Privacy Notice; reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for your entire PHI that it maintains. We will distribute any revised Privacy Notice to you prior to implementation; will not retaliate against you for filing a complaint.