Uses and Disclosures of Protected Health Information: Your protected health information (PHI) may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician's practice, and any other use required by law.

Treatment: Your protected health information (PHI) may be used by physicians and staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health care professionals who may provide treatment or who may be consulted by staff members.

Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay or procedure may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission or procedure.

Health Care Operations: Your protected health information may be used as necessary to support the business activities of your physician's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of medical students, licensing, and conducting or arranging for other business activities. For example, we may disclose your protected health information to medical school residents who see patients in our office. In addition, we may use a sign in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of you appointment.

Your PHI may be disclosed in the following situations without your authorization: Public Health issues as required by law, Communicable Diseases; Health Oversight; Abuse or Neglect; Food and Drug Administration requirements; Legal Proceedings; Law Enforcement; Coroners, Funeral Directors, and Organ Donation; Research; Criminal Activity; Military Activity and National Security; Workman's Compensation; Inmates; Required Uses and Disclosures. Under the law, we must make disclosures to you and when required by the Secretary of the Dept. of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other uses and disclosure will be made only with your consent, authorization or opportunity to object unless required by law.

Revocation of this authorization may be made in writing at any time, however, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision to revoke authorization.

Your Rights: You have certain rights under the federal law as follows:

The right to inspect and copy your protected health information with the following exceptions: psychotherapy notes; information compiled in reasonable anticipation of or use in civil, criminal or administrative actions or proceedings or protected health information that is subject to laws prohibiting access to PHI.

The right to receive confidential communications concerning your medical condition and treatment such as sending mail to an address other than your home.

The right to receive a copy of this notice from us.

The right to request restrictions on the use and disclosure of your PHI. For example you may ask us not to use or disclose any part of your PHI for the purposes of treatment or payment. You may request that any part of your PHI not be disclosed to family members or others involved in your care. Your request must state the specific restriction and to whom you want the restriction to apply. If your physician believes it is in your best interest to permit use and disclosure of your PHI, your PHI will not be restricted.

The right to request amendment or submit corrections to your PHI. If your request is denied, you have the right to file a statement of disagreement, and we may prepare a rebuttal to your statement and will provide you a copy of the rebuttal.

The right to receive an accounting of how and to whom your PHI has been disclosed.

As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Upon request, we will provide you with the most recently revised notice. The revised policies and practices will be applied to all PHI maintained in this practice.

You may request to inspect or copy the protected health information that we maintain. There will be a charge of $1.00 per page up to a maximum or $15.00 for a copy of your records. As permitted by law, we require that requests to inspect or copy PHI be submitted in writing. You may obtain a form to request to your records from our staff.

Complaints: If you have any comments or complaints about our privacy practices, or if you believe your privacy rights have been violated by us, you may notify the office manager in writing. This office will not retaliate against you for filing a complaint.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with request to Protected Health Information (PHI). If you have any objections to this form, please ask to speak with the HIPAA Compliance Officer in person or by phone.

Notice of Privacy Practices 4/14/03
Revised 9/7/03