HIPAA / Privacy Policy
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.
This notice of Privacy Practices describes how we may use and disclose your protected health information
(PHI) to carry out treatment, payment, or health care operations and for other purposes that are permitted or
require by law. It also describes your right to access and control your protected health information.
“Protected health information” is information about you, including demographic information that may
identify you and that relates to your past, present or future physical of mental health or condition and
related health care services.
Uses and Disclosures of Protected Health Information
Your protected health information 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: 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 processes care to 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.
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 may require that your relevant protected
health information be disclosed to the health plan to obtain approval for the hospital admission.
Healthcare Operations: We may use or disclose, as needed, your protected health information in order 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, an
conducting or arranging for other business activities. For example, we may disclose your protected health
information to medical school students that see patients at 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 your appointment.
We may use or disclose your protected health information in the following situations without your
authorization. These situations include: as Required by Law, Public Health issues as required by law,
Communicable Disease; Health Oversight; Abuse or Neglect; Food and Drug Administration requirements;
Criminal Activity; Military Activity and National Security; Workers’ Compensation; inmates; required
Uses and Disclosures; Under the law, we must make disclosure and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance
with requirement of Section 164.500.
Other Permitted and Required Uses and Disclosures: will be made only with your consent,
authorization or opportunity to objet unless required by law.
You may revoke this authorization, at any time, in writing, except to the extent that your physician or
the physician’s practice has taken an action I reliance on the use or disclosure indicated in the
authorization.
Your Rights
Following this statement of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information. This means you may ask us
not to use or disclose any part of your protected health information for the purposes of treatment, payment
of healthcare operations. You may also request that any part of your protected health information not be
disclosed to family members or friends who may be involved in your care or for notification purposes as
described in this Notice Of Privacy Practices. Your request must state the specific restriction requested and
to whom you want the restriction to apply.
Your physician is not required to agree to a restriction that you may request. If your physician believes it is
in your best interest to permit use and disclosure of your protected health information. Your protected
health information will not be restricted. You then have the right to use another Healthcare Professional.
You have the right to request to receive confidential communications from us by alternative means of
at an alternative location. You have the right to obtain a paper copy of this notice from us, upon
request, even if you have agreed to accept this notice alternatively i.e. electronically.
You may have the right to have your physician amend your protected health information. If we deny
your request for amendment, you have the right to file a statement of disagreement with us and we may
prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures we have made, if any, of your
protected health information. We reserve the right to change the terms of this notice and will inform
you by mail of any changes. You then have the right to object or withdraw as provided in this notice.
Complaints
You may complain to us or to the Secretary of Health and Human Services if you believe we have violated
your privacy rights. You may file a complaint with us by notifying our privacy contact of your complaint.
We will not retaliate against you for filing a complaint.
This notice was published and becomes effective on/or before April 14, 2003.
We are required by law to maintain the privacy of, and provide individuals with this notice of our legal
duties and privacy practices with respect to protected health information. If you have any objections to this
form, please ask to speak with our HIPAA Compliance Office in person or by phone at (213) 977-1211.
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