Transcription of N O T I C E O F P R I V A C Y P R A C T I C E
1 NOTICE OF PRIVACY PRACTICE THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW TO GET ACCESS TO THIS INFORMATION PLEASE REVIEW IT CAREFULLY THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US ThisnoticeofPrivacyPracticedescribeshoww emayuseanddiscloseyourprotectedhealthinf ormationtocarry outtreatment, alsodescribesyourrightstoaccessandcontro lyourprotectedhealthinformation. Protectedhealthinformation is informationaboutyou,includingdemographic information,thatmayidentifyyouandthatrel atestoyourpast, present or future physical or mental health or condition and related health care services. ,youmaychangeyourmindatany time.
2 Let us know in writing if you change your mind. Wemaychangethetermsofournotice, informationthatwemaintainatthattime, , ourwebsite,orcallingtheofficeandrequesti ngthatarevisedcopybesendtoyouinthemailor askingforonatthe time of your next appointment. USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclose health information about you for treatment, payment, and healthcare operations. For example: Payment: Wemayuseanddiscloseyourhealthinformation toaphysicianorotherhealthcareproviderpro viding treatment to you, or to family and friends you approve. HealthcareOperations:Wemayuseanddisclose yourhealthinformationinconnectionwithout healthcare ,reviewingandcompetence orqualificationsofhealthcareprofessional s,evaluatingpractitionerandproviderperfo rmance,conductingand training programs, accreditation, certification, licensing or credentialing activities.
3 YourAuthorizationandLimitations: Inadditiontoouruseofyourhealthinformatio nfortreatment,paymentor healthcareoperations,youmaygiveuswritten authorizationtouseyourhealthinformationo rtodiscloseitto (PersonalHealth Information),oralternativemeansofcommuni cation( ,homeorbusinessphone) requiredtoagreetoallrequests,andwemaysay no aserviceoritemout-of-pocketinfull,youcan askusnottosharethatinformationforthepurp oseofpaymentorour operations with your insurer. We will say yes unless a law requires us to share that information. MarketingHealth-RelatedServices :Wewillnotuseyourhealthinformationformar ketingcommunicationsor sell your health information without your written authorization.
4 RequiredbyLaw:Wemayuseordiscloseyourheal thinformationwhenwearerequiredtodosobyla wor national security activities. AbuseorNeglect: Wemaydiscloseyourhealthinformationtoappr opriateauthoritieswhenwesuspectabuseor neglect. AppointmentReminders: Wemayuseordiscloseyourhealthinformationt oprovideyouwithappointment reminders (such as voicemail messages, postcards, or letters). PATIENT RIGHTS Access: Youhavetherighttolookatorgetelectronicor papercopiesofyourhealthinformationwithli mited ,wewillchargeyouareasonablefeetolocatean dcopyyourinformation,and postage if you want the copies mailed to you. Amendment: no toyour request, but we will tell you why in writing.
5 Representative: If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information. We will make sure the person has this authority and can act for you before we take any action. QUESTIONS AND COMPLAINTS If you want more information about our privacy practices or have any questions or concerns, please contact us. If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternate locations, you may complain to us using our EthicsPoint Help Line which is (888) 366-6034.
6 You may also submit written complaint to the Department of Health and Human Services. We will provide you with the address to file your complaint with the Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with the Department of Health and Human Services. A Privacy/Contact Officer has been designated for this office. The Privacy Officer can be contacted by simply contacting the office and asking to speak to the Office Manager who serves as the Privacy Officer. PATIENT ACKNOWLEDEMENT OF THE NOTICE OF PRIVACY PRACTICES AND CONSENT FOR USE AND DISCLOSURE OF PERSONAL HEALTH INFORMATION _____ _____ Print Patients Name Date _____ _____ (Signature of Patient or Parent or Legal Guardian) Date
