This notice describes how medical information about you may be used and released and how you can get access to this information.
PLEASE REVIEW IT CAREFULLY
Effective Date: January 1, 2005
This notice applies to all records generated by your physician, office medical or billing personnel, or Business Associates.
We are required by law to maintain the privacy of your health information and provide a description of our privacy practices. We will abide by the terms of this notice and notify you if we cannot agree to a requested restriction.
We may use and release your medical information (clinical and billing) for:
- Payment, Treatment, Healthcare Operations
- Business Associates
- Appointment Reminders
- Treatment Alternative Education
- Health-related Benefits or Services
- As required by law to State/Federal Agencies
- Family or friends involved in your care
- Entities assisting in Disaster Relief
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Although your health record is the physical property of the healthcare provider, you have the Right to:
- Access Information
- Request Amendments
- An Accounting of Disclosures
- Request Privacy Restrictions
- Request Alternate Communication
- File Complaints
- Obtain a Detailed Copy of this Notice
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Please refer all requests
to our Privacy Official.
You have the right to inspect and copy medical information that may be used to make decisions about your care. Usually, this includes medical and billing records, but there are limited circumstances in which we can deny your request. These denials must be provided to you in writing, and you may request a second review in writing.
If you feel that the medical information we have about you is incorrect or incomplete, you may ask us to amend, or add to the information. You have the right to request an amendment for as long as the information is kept by or for the physician.
We may deny your request for an amendment and if this occurs, you will be notified of the reason for the denial in writing.
You have the right to request an accounting of disclosures of medical information about you. This does not include disclosures for treatment, payment, operations, or to you or your authorized representative.
You have the right to request a restriction or limitation on the medical information we use or release about you for treatment, payment or health care operations. You also have the right to request a limit on the medical information we release about you to someone who is involved in your care or the payment for your care, like a family member or friend. We are not required to agree to your request, but will do so if the request is reasonable.
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 agree to the request to the extent that it is reasonable for us to do so. We reserve the right to contact you by other means and at other locations if you fail to respond to communications from us.
You have the right to a detailed paper copy of this notice. You may ask us to give you a copy of this notice at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy of this notice.
If you believe your privacy rights have been violated, you may file a complaint with us by contacting the Privacy Official or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing.
You will not be penalized for filing a complaint.
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or release medical information about you, you may withdraw that permission, in writing, at any time.
We reserve the right to change this notice and the revised or changed notice will be effective for information we already have about you as well as any information we receive in the future. The current notice will be posted in the practice and include the effective date. We can provide additional copies of the notice when you check in for future appointments, at your request.
Privacy Official:
Dr. Rebecca Small
Phone Number:
(831) 345-9595
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