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NOTICE OF PRIVACY PRACTICES
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.
Information Portability and Accountability Act, defines these privacy practices explicitly. It also requires us to give you a basic summary of them and obtain your acknowledgement that you have received this notice.
• The law permits us to disclose your health information to those involved in your care. For example, we In our office, we have always kept your health information confidential. A new law, HIPAA or Health may forward lab results to specialists you are seeing.
• We may disclose your health information for payment purposes. For example, we may send a copy of your office visit notes to your insurance company if they request it to verify payment.
• We may disclose your health information for our normal health care operations. For example, we may send a copy of your office visit notes to your insurance company to obtain authorization for non-formulary medications.
• We may disclose your information to contact you. For example, we may call you to remind you of appointments. If you are not home, we may leave this information on your answering machine or with the person who answers the phone.
• In an emergency, we may disclose your health information to a family member or another person responsible for your care. In the event of a disaster, we may disclose information to a relief organization. If you are able and available to agree or object, we will give you the opportunity to do so before a disclosure is made; however, we
may disclose this information in a disaster over your objection if we believe it is necessary to respond to the emergency circumstances.
• We may release some or all of your health information when required by law. For example, the law requires us to report abuse or domestic violence to law enforcement officials.
• If this practice is sold, the records will become the property of the new owner. You have the right to request that copies of your health information be transferred to another physician.
• Except as described above, this practice will not use or disclose your health information without your prior written authorization.
• You may request in writing that we not use or disclose your health information as described above. We will let you know whether we can fulfill your request.
• You have the right to know any disclosures we make beyond the above normal uses.
• You have the right to request that we contact you only at specific telephone numbers or addresses. We will comply with all reasonable requests submitted in writing.
• You have the right to transfer copies of your health information to another practice.
• You have the right to inspect and/or copy your health information. To access your health information, you must submit a written request detailing what information you want and whether you wish to inspect or copy it. If you would like us to provide the copies, we will charge a reasonable fee, as allowed by law.
• There are a few exceptions to your right to access records. For example, we may deny your request to access your child’s records if we believe that allowing access would be reasonably likely to cause substantial harm to the patient. If we deny your request, you have a right to appeal.
• You have the right to request that we amend your health information if you believe it is incorrect or incomplete. You must submit a written request. We are not required to make the changes you request, but we will include your statement in your file.
• If you received this notice electronically, you have a right to request a copy of this notice in paper form.
• We reserve the right to amend this notice. If we do, a copy may be requested at your next appointment.
• If you believe we have not handled your health information appropriately, you may file a complaint with the Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, Washington, DC 20201. You will not be penalized for filing a complaint. However, before filing a complaint, or for more information or assistance regarding your health information privacy, please contact our Privacy Officer, [Name of Officer].
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Signature of Patient (or Parent or Guardian) Date
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Signature of Practitioner Date
Copy to: patient, patient chart