1. USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION: Your protected health information may be used by your health care provider for treatment, payment and health care operations as described in this section without authorization from you. Your protected health information may be used and disclosed by your health care provider, 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. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of the health care provider’s practice. We will share your protected health information with third party “business associates” that perform various activities (e.g., billing, accounting services, legal services, IT services, home healthcare agencies, accreditation organizations, collection agencies, 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 health information. We may use or disclose your protected health information, as necessary, to provide you with information about a product or service to encourage you to purchase or use the product or services for the following limited purposes: (1) to describe our participation in a health care provider network or health plan network, or to describe if, and the extent to which, a product or service (or payment for such product or service) is provided by our practice or included in a plan of benefits; (2) for your treatment; or (3) for your case management or care coordination, or to direct or recommend alternative treatments, therapies, health care providers, or settings of care. In addition, we may disclose your protected health information to another provider, health plan, or health care clearinghouse for limited operational purposes of the recipient, as long as the other entity has, or has had, a relationship with you. Such disclosures shall be limited to the following purposes: quality assessment and improvement activities, case management, conducting training programs, accreditation, certification, licensing, credentialing activities, and health care fraud and abuse detection and compliance programs.
Uses and Disclosures of Protected Health Information Based upon Your Written Authorization: Other uses and disclosures of your protected health information will be made only with your written authorization, unless otherwise permitted or required by law. You may revoke this authorization, at any time, in writing, except to the extent that your health care provider or the provider’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.
2. YOUR RIGHTS: Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.
You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected health information about you that is contained in a designated record set for as long as we maintain the protected health information. A “designated record set” contains medical and billing records and any other records that your health care provider and the practice uses for making decisions about you. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; and protected health information that is subject to law that prohibits access to protected health information. Depending on the circumstances, a decision to deny access may be reviewable. In some circumstances, you may have a right to have this decision reviewed. Please contact our Privacy Contact if you have questions about access to your medical record.
You have the right to request a restriction of 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 or 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. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your health care provider is not required to agree to a restriction that you may request. If your health care provider 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. If your health care provider does agree to the requested restriction, we may not use or disclose your protected health information in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your health care provider. You may request for special restrictions, verbally or in writing. Once we receive the appropriate form, the necessary steps will be taken by our Privacy Officer.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be handled or specification of an alternative address or other method of contact. We will not request an explanation from you as to the basis for the request. Please make this request in writing to our Privacy Officer.
You may have the right to have your provider amend your protected health information. This means you may request an amendment of protected health information about you in a designated record set for as long as we maintain this information. In certain cases, we may deny your request for an amendment. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a response to your statement and will provide you with a copy of any such response. Please contact our Privacy Officer to determine if you have questions about amending your medical record.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice. It excludes disclosures we may have made to you, for a facility directory (if applicable), to family members or friends involved in your care, or for notification purposes, or disclosures for which you have signed an authorization. You have the right to receive specific information regarding these disclosures that occurred after October 7th, 2013. You may request a shorter time frame. The right to receive this information is subject to certain exceptions, restrictions and limitations.
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 electronically.
3. COMPLAINTS: You may complain to us or to the Department of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our Privacy Officer of your complaint. We will receive all complaints and concerns in privacy and will be considered it an opportunity for improvement. You may contact our Facility Privacy Official, Joseph Raymond by dialing 1.888.344.2947 or emailing email@example.com for further information about the complaint process.