OF PRIVACY PRACTICES Effective
Due to new Federal health
information privacy rules, this notice is provided to describe how information
about you be disclosed and how you can get access to this information.
PLEASE REVIEW IT CAREFULLY.
Understanding your health
A record is made each time you visit our office. Information
about your examination and test results are recorded. These records provide
information about your treatment as well as research data.
Understanding what information is retained in your
record and how that information may be used will help you to ensure its
accuracy, and enable you to know who, when, where, and why others may be
allowed access to your health information. This effort is being made to assist
you in making informed decisions before authorizing the disclosure of your
medical information to others. Use or
disclosure of your health information will follow the stringent State or
Understanding your privacy rights
record is the physical property of the health care practitioner or facility
that compiled it but the content is about you, and therefore belongs to
•You have the right to a list of disclosures of your
health information for up to 6 years prior to the date of your request. This does not include: (1) disclosures made
for treatment and healthcare operations as described below; or (2) disclosures
made in circumstances where you have given authorization or (3) other
disclosures made in accordance with the law.
•Other than activity that has already occurred, you
have the right to revoke any further authorizations to use or disclose your
•You also have the right to request that medical
information about you be communicated by alternative means to maintain
confidentiality, such as sending your mail to an address other than your home.
• In most cases, you have the right to review or
obtain a copy of your health information.
To do so, you must submit a written request to the address below. If we deny your request, you are entitled to
a review of that decision.
•You have the right to request restrictions on certain
uses and disclosures of your information, and to request amendments be made to
your health record.
Institutions’ Privacy Practices
We understand that health information about you is
personal, and we are committed to protecting that information. In meeting legal requirements and honoring our
promise to protect your health information we:
Keep your medical
information private. Other than for
reasons described in this notice, this office agrees not to use or disclose
your health information to individuals who without your authorization.
Provide you with
this notice of your rights and our legal commitment and privacy practices with
respect to the information we collect and maintain about you.
Abide by the
terms of this notice and notify you if we are unable to grant your requested
restrictions or reasonable desires to communicate your health information by
alternative means or to alternative locations.
Take all possible
steps to safeguard your health information.
Ensure that all
healthcare professionals and individuals with privileges, including staff members
Understanding our office
policy for specific disclosures
• Authorization – As a research participant, your health
information will be disclosed to those you have specifically authorized to
receive this information.
• Business Associates – Some or all of
your health information may be subject to disclosure through contracts for
services to assist this office in providing services. To protect your health information, we
require these Business Associates to follow the same standards held by this
office through terms detailed in a written agreement.
• Communications with Family– Using best
judgment, a family member, or close personal friend, identified by you, may be
given information relevant to your care.
•Health Care Operations - The medical staff in this office will use your health
information to assess the care you received and the outcome of your case
compared to others like it. Your
information may be reviewed in our efforts to continually improve the quality
and effectiveness of the care and services we provide.
• Limited Data Set – We may use or disclose information about you without
your authorization as part of a “limited data set” which includes limited
information (such as a city, but not your name or address) for research
purposes. The recipient of this information
must sign a promise to restrict the use of this information.
• Marketing – This office reserves the
right to contact you with appointment reminders or information about treatment
alternatives and other health-related services that might be appropriate to
• Fund Raising – We reserve the right to contact you as
part of fundraising efforts.
• Food and Drug Administration (FDA) – This
office is required by law to disclose health information to the FDA related to
any adverse effects of food, supplements, products, and product defects for
surveillance to enable product recalls, repairs, or replacements.
• Public Health – This office is
required by law to disclose health information to public health and/or legal
authorities charged with tracking mandatory reports of health statistics, such
as injuries and communicable diseases.
• Law Enforcement – (1) Your health
information will be disclosed for law enforcement purposes as required under
state law or in response to a valid subpoena. (2) Provisions of federal law
permit the disclosure of your health information to appropriate health
oversight agencies and authorities when
a report is made in good faith that there has been unlawful conduct or
violations of professional clinical standards.
•Treatment – Your health information is used for
research purposes, and in some cases to help determine the course of your treatment. In those cases, the sharing of your health
information may with others involved in your treatment, such as specialty
physicians or lab technicians.
If we have a change in
This office reserves the right to change its practices,
and affect new policy to enhance the privacy standards of research participant
records. You will be informed of changes
at your research visits. This office
will also post changes to this notice on our websites.
For additional information or to report a problem
For further explanation of this notice you may contact
our Privacy Officer at
If you believe your privacy rights have been violated, you have the
right to file a complaint with this office by contacting the individual above,
contacting the Secretary of the U.S. Department of Health
and Human Services, with no fear of retaliation by this office.
NOTICE OF PRIVACY
The terms described in this notice
will be posted in the office and on the organizations’ websites. All individuals receiving care will be given
a hard copy. We have asked that you
acknowledge receipt of this notice, as such it is expected that you have read