THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION
PLEASE REVIEW THIS INFORMATION CAREFULLY IT IS IMPORTANT TO US THAT YOU KNOW YOUR RIGHTS
OUR LEGAL OBLIGATIONS, USES AND DISCLOSURE OF HEALTH INFORMATION AND YOUR RIGHTS
We are required by applicable federal law to maintain the privacy of your health information. This notice provides you with information on the Privacy Practices we have adopted to maintain the privacy of your health information and is effective as of the date noted above until we change the practices and notify you of such changes. We reserve the right to change our privacy practices. If we make a change, it will be in compliance with applicable laws that govern the protection of your privacy. You may request a copy of our privacy notice at any time. You have certain rights that are described in this notice. Please review it carefully and understand the rights that you have, our policies that have been implemented to protect your rights and our obligations under applicable law. A privacy officer is named at the end of this notice. Please contact the privacy officer if you have further questions about our policies.
USE AND DISCLOSURE- YOU’RE PROTECTED HEALTH INFORMATION AND OUR POLICIES: We use and disclose health information about you to other treatment providers for treatment purposes, for payment purposes and for healthcare operations.
TREATMENT: We use your information and we may disclose your information to other healthcare providers that provide treatment to you.
PAYMENT: We may use your information for payment purposes so we may receive payments for the services provided to you.
OPERATIONS: We may disclose and/or use health information for purposes of healthcare operations which can include audits by regulatory agencies and other authorized agencies, assessment activities of our business and how it operates, to maintain and manage our healthcare systems that are used in our business, to review the qualifications and competence of our employees or other healthcare providers, evaluating performance, for purposes of accreditation or certification, for training and for other healthcare operations that must be conducted in order for us to operate our business and provide healthcare for you.
AUTHORIZATION FOR USE OF HEALTH INFORMATION: In addition to the use of information for purpose of treatment, payment and operations, we also may obtain your authorization to disclose your protected health information to others, If you give us a written authorization to disclose your information, you may revoke that permission at any time, in writing, by delivering a copy of h revocation to us. The revocation is only effective after we have received it and does not apply to information disclosed pursuant to the authorization prior to our receiving your revocation notice. We will not disclose your protected health information, except for the reasons set forth in this notice and unless such disclosure in incidental or made pursuant to the applicable federal and/or state law. Unless we have your authorization to do so. We may also discuss health information verbally with you in our office or facilities and will keep such discussions with you private. In the event others are present in our office or facility and may be able to hear our discussions, we will notify you before we begin talking with you about your health information and you will have the opportunity to have the discussion in a private room, office or other location.
INCIDENTAL DISCLOSURE: If a family member or a friend is present and we are discussing your health information with them, you understand that such discussions are made with your permission. We will ask you for your permission if such a situation exists.
PERSONS TREATING YOU OR PROVIDING CARE OR SERVICES FOR YOU: Our office may use or disclose information to notify or assist in the location and/or notification of your family member, your personal representative or any other person responsible for your case and general condition. If you are present, then prior to the use or disclosure of your protected health information, you have the opportunity to object by telling us you do not want the information disclosed to the third party. In the event of an emergency or your incapacity, we will disclose information based on our professional judgment. The information we disclose will be limited to that information directly related to your treatment in the particular circumstance. In any case, we will use our professional judgment and will follow our general policies and practices to make reasonable determinations with respect to allowing a person to pick-up prescriptions, medical supplies, x-rays or other similar forms of health materials and/or information.
MARKETING: We will not use your health information for marketing communications without your written authorization unless the communication relates specifically to your treatment. When we believe materials may assist you in respect to your treatment, we may directly provide you with information about treatment options, including products and/or services that we believe, in our professional judgment, are important for you.
ABUSE, NEGLECT AND OTHER RELATED CIRCUMSTANCES: We may disclose your health information to appropriate authorities if we reasonable believe that you are a possible victim of abuse, neglect or domestic violence. We may also disclose the information to avert a serious health crisis that could affect you or the health or the safety of others.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE
PLEASE REVIEW THIS ACKNOWLEDGEMENT AND SIGN BELOW AFTER YOU HAVE RECEIVED THE INFORMATION THAT HAS BEEN CHECKED ON THE LIST SHOWN BELOW: