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Notice of Privacy Practices for Protected Health Information


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:

Example of use of you health information for payment purposes:

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

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:

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.

Other Disclosures and Uses We Can Make Without Your Written Authorization

Notification of Family/Friends

Communication with Family/Friends

Disaster Relief


Deceased Persons

Appointment Reminders/Treatment Alternatives


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:

Sign in Sheet

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