This notice describes how medical and personal identifying information about you may be used and disclosed and how you can get access to this information. Please review this notice carefully.
Your health record contains personal information about you and your health. State and federal law protects the confidentiality of this information. "Protected health information"(PHI) is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services. If you suspect a violation you may file a report to the appropriate authorities in
accordance with Federal regulations.
You have the following rights regarding PHI (Protected health information) we maintain about you:
Right of Access to Inspect and Copy. You have the right, which may be restricted only in certain limited circumstances, to inspect and copy PHI that may be used to make decisions about your care. We may charge a reasonable, cost-based fee for copies.
Right to Amend. If you feel that the PHI I have about you is incorrect or incomplete, you may ask me to amend the information although we are not required to agree to the amendment.
Right to an Accounting of Disclosures. You have the right to request a copy of the required accounting of disclosures that we make of your PHI.
Right to Request Restrictions. You have the right to request a restriction or limitation on the use or of your PHI for treatment, payment, or health care operations. We are not required to agree to your request.
Right to Request Confidential Communication. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. We will accommodate reasonable requests and will not ask why you are making the request.
Right to a Copy of this Notice. You have the right to a paper copy of this notice.
Right of Complaint. You have the right to file a complaint in writing with me or with the Secretary of Health and Human Services if you believe I have violated your privacy rights. We will not retaliate against you for filing a complaint.
Treatment. Your PHI may be used and disclosed by us for the purpose of providing, coordinating, or managing your health care treatment and any related services. This may include coordination or management of your health care with a third party, consultation with other health care providers or referral to another provider for health care services.
Payment. We will not use your PHI to obtain payment for your health care services without your written authorization. Examples of payment-related activities are: making a determination of eligibility or coverage for insurance benefits, processing claims with your insurance company, reviewing services provided to you to determine medical necessity, or undertaking utilization review activities.
Healthcare Operations. We may use or disclose, as needed, your PHI in order to support the business activities of my professional practice. Such disclosures could be to others for health care education, or to provide planning, quality assurance, peer review, administrative, legal, or financial services to assist in the delivery of health care, provided we have a written contract requiring the recipient(s) to safeguard the privacy of your PHI. We may also contact you to remind you of your appointments, inform you of treatment alternatives and/or health-related products or services that may be of interest to you.
Required by Law. We may use or disclose your PHI to the extent that the use or disclosure is required by law, made in compliance with the law, and limited to the relevant requirements of the law. Examples are public health reports and law enforcement reports. We also must make disclosures to the Secretary of the Department of Health and Human Services for the purpose of investigating or determining my compliance with the requirements of the Privacy Rule.
Health Oversight. We may disclose PHI to a health oversight agency for activities authorized by law, such as professional licensure. Oversight agencies also include government agencies and organizations that provide financial assistance to me (such as third-party payers).
Abuse or Neglect. We may disclose your PHI to a state or local agency that is authorized by law to receive reports of abuse or neglect. However, the information we disclose is limited to only that information which is necessary to make the initial mandated report. Disclose PHI regarding deceased patients for the purpose of determining the cause of death, in connection with laws requiring the collection of death or other vital statistics, or permitting inquiry into the cause of death.
Research. We may disclose PHI to researchers if (a) an Institutional Review Board reviews and approves the research and an authorization or a waiver to the authorization requirement; (b) the researchers establish protocols to ensure the privacy of your PHI; and (c) the researchers agree to maintain the security of your PHI in accordance with applicable laws and regulations.
Threat to Health or Safety. We may disclose PHI when necessary to prevent a serious threat to your health and safety or the health and safety to the public or another person.
Criminal Activity on Business Premises/Against Staff. We may disclose your PHI to law enforcement officials if you have committed a crime on our premises or against our staff.
Compulsory Process. We will disclose your PHI if a court of competent jurisdiction issues an appropriate order. We will disclose your PHI if you and Communicating Potential have each been notified in writing at least fourteen in advance of a subpoena or other legal demand, and no protective order has been obtained, and we have satisfactory assurances that you have received notice of an opportunity to have limited or quashed the discovery demand.
Other uses and disclosures of your PHI will be made only with your written authorization. You may revoke this authorization in writing at any time; unless we have taken an action in reliance on the authorization of the use or disclosure you permitted, such as providing you with health care services for which we must submit subsequent claim(s) for payment.
This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) in accordance with all applicable law. It also describes your rights regarding how you may gain access to and control your PHI. We are required by law to maintain the privacy of PHI and to provide you with notice of our legal duties and privacy practices with respect to PHI. I am required to abide by the - terms of this Notice of Privacy Practices. We reserve the right to change the terms of my Notice of Privacy Practices at any time. Any
new Notice of Privacy Practices will be effective for all PHI that we maintain at that time. We will make available a revised Notice of Privacy Practices by providing one to you at your next appointment or mailing you a copy at your request.
If you believe we have violated your privacy rights, you may file a complaint in, writing to us, as specified in the "Contact Information" section of this Notice. We will not retaliate against you for filing a complaint. You may also file a complaint with the U.S. Secretary of Health and Human Services.
If you have any questions about this Notice of Privacy Practices, please
contact firstname.lastname@example.org by email or 425-679-9820 by phone or 208-643-7434 by fax.