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.
My commitment to your privacy
My practice is dedicated to maintaining the privacy of your personal health information as part of providing professional care. I am also required by law to keep your information private. These laws are complicated, but I must give you this important information. This is a shorter version of the full, legally required notice of privacy practices available via email, postal mail, and in person. Please see the privacy officer (designated at the end of this page) about any questions or problems.
How I use and disclose your protected health information with your consent
I will use the information I collect about you to mainly to provide you with treatment, to arrange for payment for services, and for some business activities that are called, in the law, health care operations. After you have read this notice I will ask you to sign a consent form allowing me to use and share your information in these ways. If you do not consent and sign this form, I cannot treat you.
If I want to use or send, share, or release your information for other purposes, I will discuss this with you and ask you to sign an authorization form to allow this.
Disclosing your health information without your consent
There are some times when the laws require me to use or share your information. For example:
1. When there is a serious threat to your or another’s health and safety or to the public. I will only share information with persons who are able to help prevent or reduce the threat.
2. When I am required to do so by lawsuits and other legal or court proceedings.
3. If a law enforcement official requires me to do so.
4. For worker’s compensation and other similar benefit programs.
Your rights regarding your health information
1. You can ask me to communicate with you in a particular way or at a certain place that is more private for you. For example, you can ask me to call you at home, and not work, to schedule or cancel an appointment. I will try my best to do as you ask.
2. You can ask me to limit what I tell people involved in your care or the payment for your care, such as family members or friends.
3. You have the right to look at the health information I have about you, such as your medical and billing records. You can get a copy of these records, but I may charge you for it. Contact the privacy officer to see how you can get a copy of these records. See below.
4. If you believe that the information in your records is incorrect or missing something important, you can ask me to make additions to your record to correct the situation. You have to make this request in writing and send it to the privacy officer. You may also tell me the reasons you want to make the changes.
5. You have the right to a copy of this notice. If I change this notice, I will post the new version in the office and you can always get a copy of it from the privacy officer.
6. You have the right to file a complaint if you believe your privacy rights have been violated. You can file a complaint with our privacy officer and with the Secretary of the U.S. Department of Health and Human Services. All complaints must be in writing. Filing a complaint will not change the health care I provide to you in any way.
Also, you may have other rights that are granted to you by the laws of our state, and these may be the same as or different from the rights described above. I will be happy to discuss these situations with you now or as they arise. If you have any questions regarding this notice or the health information privacy practices, please contact the privacy officer for this practice, Dr. Nicole Robinson, who can be reached by phone at 718-370-2155 or by email at email@example.com. The effective date of this notice is December 20, 2011.
This form was modified with permission from The Paper Office. Copyright 2008 by Edward L. Zuckerman.