THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
REVIEW IT CAREFULLY. THE PRIVACY OF YOUR MEDICAL INFORMATION IS IMPORTANT TO
Our Legal Duty
We are required by
applicable federal and state laws to maintain the privacy of your protected
health information. We are also required to give you this notice about our
privacy practices, our legal duties, and your rights concerning your protected
health information. We must follow the privacy practices that are described in
this notice while it is in effect. This notice takes effect April 14, 2003,
and will remain in effect until we replace it.
We reserve the right
to change our privacy practices and the terms of this notice at any time,
provided that such changes are permitted by applicable law. We reserve the
right to make the changes in our privacy practices and the new terms of our
notice effective for all protected healthin formation that we maintain,
including medical information we created or received before we made the
You may request a copy of our notice (or any subsequent
revised notice) at any time. For more information about our privacy practices,
or for additional copies of this notice, please contact us using the
information listed at the end of this notice.
Uses and Disclosures of Protected Health Information
We will use and disclose your protected health information about you
for treatment, payment, and health care operations. Following are examples of
the types of uses and disclosures of your protected health care information
that may occur. These examples are not meant to be exhaustive, but to describe
the types of uses and disclosures that maybe made by our office.
We will use and disclose your protected health information to provide,
coordinate or manage your healthcare 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 provides care to you. We will also disclose
protected health information to other physicians who may be treating 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.
In addition, we may disclose
your protected health information from time to time to another physician or
health care provider (e.g., a specialist or laboratory)who, at the request of
your physician, becomes involved in your care by providing assistance with
your health care diagnosis or treatment to your physician.
Your protected health information will be used, as needed, to obtain payment
for your health care services. This may include certain activities that your
health insurance plan may undertake before it approves or pays for the health
care services we recommend for you, such as: making a determination of
eligibility or coverage for insurance benefits, reviewing services provided to
you for protected health necessity, and undertaking utilization review
activities. 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.
Operations: We may use or disclose, as needed, your protected health
information in order to conduct certain business and operational activities.
These activities include, but are not limited to, quality assessment
activities, employee review activities, training of students, licensing, and
conducting or arranging for other business activities.
we may use a sign-in sheet at the registration desk where you will be asked to
sign your name. We may also call you by name in the waiting room when your
doctor is ready to see you. We may use or disclose your protected health
information, as necessary, to contact you by telephone or mail to remind you
of your appointment.
We will share your protected health
information with third party "business associates" that perform various
activities (e.g., billing, transcription services) for the practice. Whenever
an arrangement between our office and a business associate involves the use or
disclosure of your protected health information, we will have a written
contract that contains terms that will protect the privacy of your protected
We may use or disclose your protected health
information, as necessary, to provide you with information about treatment
alternatives or other health-related benefits and services that may be of
interest to you. We may also use and disclose your protected health
information for other marketing activities. For example, your name and address
may be used to send you a newsletter about our practice and the services we
offer. We may also send you information about products or services that we
believe may be beneficial to you. You may contact us to request that these
materials not be sent to you.
Uses and Disclosures Based On Your
Written Authorization:Other uses and disclosures of your protected health
information will be made only with your authorization,unless otherwise
permitted or required by law as described below.
You may give us
written authorization to use your protected health information or to disclose
it to anyone for any purpose. If you give us an authorization, you may revoke
it in writing at any time. Your revocation will not affect any use or
disclosures permitted by your authorization while it was in effect. Without
your written authorization, we will not disclose your health care information
except as described in this notice.
Others Involved in Your Health
Care: Unless you object, we may disclose to a member of your family, a
relative, a close friend or any other person you identify, your protected
health information that directly relates to that person's involvement in your
health care. If you are unable to agree or object to such a disclosure, we may
disclose such information as necessary if we determine that it is in your best
interest based on our professional judgment. We may use or disclose protected
health information to notify or assist in notifying a family member, personal
representative or any other person that is responsible for your care of your
location, general condition or death.
Marketing: We may use your
protected health information to contact you with information about treatment
alternatives that may be of interest to you. We may disclose your protected
health information to a business associate to assist us in these activities.
Unless the information is provided to you by a general newsletter or in person
or is for products or services of nominal value, you may opt out of receiving
further such information by telling us using the contact information listed at
the end of this notice.
Research; Death; Organ Donation: We may use
or disclose your protected health information for research purposes in limited
circumstances. We may disclose the protected health information of a deceased
person to a coroner, protected health examiner, funeral director or organ
procurement organization for certain purposes.
Public Health and
Safety: We may disclose your protected health information to the extent
necessary to avert a serious and imminent threat to your health or safety, or
the health or safety of others. We may disclose your protected health
information to a government agency authorized to oversee the health care
system or government programs or its contractors, and to public health
authorities for public health purposes.
Health Oversight: We may
disclose protected health information to a health oversight agency for
activities authorized by law, such as audits, investigations and inspections.
Oversight agencies seeking this information include government agencies that
oversee the health care system, government benefit programs, other government
regulatory programs and civil rights laws.
Abuse or Neglect: We may
disclose your protected health information to a public health authority that
is authorized by law to receive reports of child abuse or neglect. In
addition, we may disclose your protected health information if we believe that
you have been a victim of abuse, neglect or domestic violence to the
governmental entity or agency authorized to receive such information. In this
case, the disclosure will be made consistent with the requirements of
applicable federal and state laws.
Food and Drug Administration: We
may disclose your protected health information to a person or company required
by the Food and Drug Administration to report adverse events, product defects
or problems, biologic product deviations; to track products; to enable product
recalls; to make repairs or replacements; or to conduct post marketing
surveillance, as required.
Criminal Activity: Consistent with
applicable federal and state laws, we may disclose your protected health
information, if we believe that the use or disclosure is necessary to prevent
or lessen a serious and imminent threat to the health or safety of a person or
the public. We may also disclose protected health information if it is
necessary for law enforcement authorities to identify or apprehend an
Required by Law: We may use or disclose your protected
health information when we are required to do so by law. For example, we must
disclose your protected health information to the U.S. Department of Health
and Human Services upon request for purposes of determining whether we are in
compliance with federal privacy laws. We may disclose your protected health
information when authorized by workers' compensation or similar laws.
and Proceedings: We may disclose your protected health information in response
to a court or administrative order, subpoena, discovery request or other
lawful process,under certain circumstances. Under limited circumstances,such
as a court order, warrant or grand jury subpoena, wemay disclose your
protected health information to law enforcement officials.
Enforcement: We may disclose limited information to a law enforcement official
concerning the protected health information of a suspect, fugitive, material
witness, crime victim or missing person. We may disclose the protected health
information of an inmate or other person in lawful custody to a law
enforcement official or correctional institution under certain circumstances.
We may disclose protected health information where necessary to assist law
enforcement officials to capture an individual who has admitted to
participation in a crime or has escaped from lawful custody.
Access: You have the right to look at or get copies of your protected
health information, with limited exceptions. You must make a request in
writing to the contact person listed herein to obtain access to your protected
health information. You may also request access by sending us a letter to the
address at the end of this notice. If you request copies, we will charge you
$25.00 for each page or$10.00 per hour to locate and copy your protected
health information, and postage if you want the copies mailed to you. If you
prefer, we will prepare a summary or an explanation of your protected health
information for a fee. Contact us using the information listed at the end of
this notice for a full explanation of our fee structure.
of Disclosures: You have the right to receive a list of instances in which we
or our business associates disclosed your protected health information for
purposes other than treatment, payment, health care operations and certain
other activities after April 14, 2003. After April14, 2009, the accounting
will be provided for the past six(6) years. We will provide you with the date
on which we made the disclosure, the name of the person or entity to whom we
disclosed your protected health information, a description of the protected
health information we disclosed, the reason for the disclosure, and certain
other information. If you request this list more than once in a12-month
period, we may charge you a reasonable, cost-based fee for responding to these
additional requests. Contact us using the information listed at the end of
this notice for a full explanation of our fee structure.
Requests: You have the right to request that we place additional restrictions
on our use or disclosure of your protected health information. We are not
required to agree to these additional restrictions, but if we do, wewill abide
by our agreement (except in an emergency). Any agreement we may make to a
request for additional restrictions must be in writing signed by a person
authorized to make such an agreement on our behalf. We will not be bound
unless our agreement is so memorialized in writing.
Communication: You have the right to request that we communicate with you in
confidence about your protected health information by alternative means or to
an alternative location. You must make your request in writing. We must
accommodate your request if it is reasonable, specifies the alternative means
or location,and continues to permit us to bill and collect payment from
Amendment: You have the right to request that we amend your
protected health information. Your request must be in writing, and it must
explain why the information should be amended. We may deny your request if we
did not create the information you want amended or for certain other reasons.
If we deny your request, we will provide you a written explanation. You may
respond with a statement of disagreement to be appended to the information you
wanted amended. If we accept your request to amend the information, we will
make reasonable efforts to inform others, including people or entities you
name, of the amendment and to include the changes in any future disclosures of
Electronic Notice: If you receive this notice on
our website or by electronic mail (e-mail), you are entitled to receive this
notice in written form. Please contact us using the information listed at the
end of this notice to obtain this notice in written form.
Questions and Complaints
If you want more information about our privacy practices or have
questions or concerns, please contact us using the information below. If you
believe that we may have violated your privacy rights, or you disagree with a
decision we made about access to your protected health information or in
response to a request you made, you may complain to us using the contact
information below. You also may submit a written complaint to the U.S.
Department of Health and Human Services. We will provide you with the address
to file your complaint with the U.S. Department of Health and Human Services
We support your right to protect the privacy of your
protected health information. We will not retaliate in anyway if you choose to
file a complaint with us or with the U.S. Department of Health and Human
Name of Contact Person: Jeremiah J.
Address: 6447-B S. East St.