Notice of Privacy Practices for Protected Health Information

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 office is required by federal regulation, known as the HIPAA Privacy Rule, to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices. This office will not use or disclose your health information except as described in this Notice.

The office is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. The health information about you is documented in a medical record and on a computer. Such information may include documenting your symptoms, medical history, examination and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those services.

Example of uses of your health information for treatment purposes:

• A nurse or medical assistant obtains treatment information about you and records it in a health record. During the course of your treatment, the physician and/or his physician assistant determines you may need to consult with another specialist. He will share the information with such specialist and obtain his/her input.

Example of use of you health information for payment purposes:

• We submit requests for payment to your health insurance company (i.e.: claims for professional services). The insurance company (or other business associate helping us obtain payment) requests health information from us regarding medical care given. We will provide information to them about you and the care given, which may include copies or excerpts of your medical record which are necessary for payment of your account.

Example of use of your health information for health care operations:

• We obtain services from our insurers or other business associates (an individual or ) for treatment, payment, or health care operations; disclosures or uses made to you or made at your request; uses or disclosures made pursuant to an authorization signed by you; or to family members or friends or uses relevant to that person's involvement in your care or in payment for such care; or uses or disclosures to notify family or others responsible for your care of your location, condition, or your death; we may charge a cost-based fee for more than one accounting in a 12-month period.
   

• Request that confidential communication of your PHI be made by alternative means or at an alternative location by delivering the request in writing to our office using the form we provide to you upon request; and,
   

• Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office.

To exercise any of the above rights, please contact Pat Salerno, Privacy Officer, in person or in writing, during normal business hours. Our Privacy Officer will provide you with assistance on the steps to take to exercise your rights.

You have the right to review this Notice before signing the acknowledgement authorizing use and disclosure of your PHI for treatment, payment, and health care operations purposes.

Our Responsibilities

Our office is required to:

• Maintain the privacy of your health information as required by law;
   

• Provide you with a notice as to our duties and privacy practices as to the information we collect and maintain about you;
   

• Abide by this Notice;
   

• Notify you if we cannot accommodate a requested restriction or request; and accommodate your reasonable requests regarding methods to communicate health information with you.

We reserve the fight to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the PHI we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by call and requesting a copy of our Notice or by visiting our office and picking up a copy.

To Request Information of File a Complaint

If you have questions, would like additional information, want to report a problem regarding the handling of your information, or if you believe your privacy fights have been violated and wish to file a written complaint with our office. You may also file a complaint by mailing it or e-mailing it to the Secretary of Health and Human Services.

• We Cannot, and will not, require you to waive your fights under the Privacy Rule including the fight to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the office.
   

• We cannot, and will not, retaliate against you for filing a complaint with HHS.

Other Disclosures and Uses We Can Make Without Your Written Authorization

Notification of Family/Friends

• Unless you object, we may use or disclose your PHI to notify, or assist in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or your death.

Communication with Family/Friends

• Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person's involvement in your care or in payment for such care if you do not object or in an emergency.

Disaster Relief

• We may use and disclose your I'M to assist in disaster relief efforts.
   

Employers

• We may release I'M to your employer if we provide health care services to you at the request of your employer, and the health care services are provided either to conduct an evaluation relating to medical surveillance of the workplace or to evaluate whether you have a work-related illness or injury. In such circumstances, we will give you written notice of such release of information to your employer. Any other disclosures to your employer will be made only if you execute an authorization for the release of that information to your employer.

Deceased Persons

• We may disclose your PHI to funeral directors, medical examiners, or coroners consistent with applicable law to allow them to carry out their duties.

Appointment Reminders/Treatment Alternatives

• We may contact you to provide you with appointment reminders or with information about a health related product we may encourage you to purchase. We will not disclose your health information without your written authorization.

FDA

• We may disclose to the FDA your health information relating to adverse events with respect to food, supplements, products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.

Entity under contract with us to perform or assist us in a function or activity that necessitates the use or disclosure of health information) such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical transcription, medical review, legal services, and insurance. We will share health information about you with our insurers or other business associates as necessary to obtain these services. We require our insurers to protect the confidentiality of your health information.

Your Health Information Rights

The health and billing records we maintain are the physical property of the doctor's office. The information in it, however, belongs to your. You have the right to:

• Request a restriction on certain uses and disclosures of your health information by delivering the requests in writing to our office-we are not required to grant the request but we will comply with any request granted.
   

• Obtain a paper copy of the Notice of Privacy Practices for Protected Health information by making a request at our office;
   

• Request that your be allowed to inspect and copy your medical and billing record-you may exercise this fight by delivering the request 'in writing to our office using the form we provide to you upon request;
   

• Appeal a denial of access to your PHI except in certain circumstances;
   

• Request that your medical record be amended to correct incomplete or incorrect information by delivering a written request, including a reason to support it, to our office using the form we provide you upon request. We are not required to make such amendments;
   

• File a statement of disagreement if your amendment is denied, and require that the request for amendment and any denial be attached in all future disclosures of your PHI;
   

Sign in Sheet

• We may use and disclose your PHI by having you sign in when you arrive at our office and by calling your name when we are ready to see you.

Other disclosures include: Public Health, Abuse, Neglect & Domestic Violence; Law Enforcement; Correctional Institutions; Health Oversight Agencies; Judicial/Administrative Agencies; to avert Serious Threat; for Specialized Government Functions; and will be made only as otherwise authorized by law or with your with your written authorization and you may revoke the authorization as previously provided in this Notice.

Original Effective Date: April 14, 2003