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.
The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program
that requires that all medical records and other individually identifiable health information
used or disclosed by us in any form, whether electronically, on paper, or orally, are kept
properly confidential. This Act gives you, the patient, significant new rights to understand and
control how your health information is used. We are required by law to maintain the privacy
of your protected health information and to provide you with notice of our legal duties and
privacy practices with respect to protected health information. HIPAA provides penalties for
covered entities that misuse personal health information.
As required by HIPAA, we have prepared this explanation of how we are required to maintain the
privacy of your health information and how we may use and disclose your health information.
Treatment means providing, coordinating, or managing health care and related services, by one
or more health care providers. An example of this would include a physical examination.
Payment means such activities as obtaining reimbursement for services, confirming coverage,
billing or collections activities, and utilization review. An example of this would be sending a
bill for your visit to your insurance company for payment.
Health care operations include the business aspects of running our practice, such as conducting
quality assessment and improvement activities, auditing functions, cost-management analysis,
and customer service. An example would be an internal quality assessment review.
We may create and distribute de-identified health information by removing all references to
individually identifiable information.
We may contact you to provide appointment reminders or information about treatment
alternatives or other health-related benefits and services that may be of interest to you.
Any other uses and disclosures will be made only with your written authorization. You may
revoke such authorization in writing and we are required to honor and abide by that written
request, except to the extent that we have already taken actions relying on your authorization.
You have the following rights with respect to your protected health information, which you
can exercise by presenting a written request to the Privacy Officer:
The right to request restrictions on certain uses and disclosures of protected health information,
including those related to disclosure to family members, other relative, close personal friends,
or any other person identified by you. We are, however, not required to agree to a requested
restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to
remove it.
The right to reasonable requests to receive confidential communications of protected health
information from us by alternative means or at alternative locations.
The right to inspect and copy your protected health information.
The right to amend your protected health information.
The right to obtain a paper copy of this notice from us upon request.
This notice is effective as of April 14, 2003 and we are required to abide by the terms of the
Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our
notice of Privacy Practices and to make the new notice provisions effective for all protected
health information that we maintain. We will post and you may request a written copy of a revised
Notice of Privacy Practices from this office.
You have recourse if you feel that your privacy protections have been violated.
You have the
right to file written complaints with our office, or with the Department of Health & Human
Services, Office of Civil Rights, about violations of the provisions of this notice or the polices
and procedures of our office. We will not retaliate against you for filing a complaint.
Please contact the following for more information:
The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
(202) 619-0257
Toll Free: 1-877-696-6775
