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.
Our Pledge Regarding Medical Information
We are committed to protecting medical information about you. This notice describes our privacy practices and that of all its employees and staff. This notice will tell you about the ways in which we may use and disclose medical information about you. It also describes your rights and certain obligations we have regarding the use and disclosure of medical information. We are required by law to:
- Give you this notice of our legal duties and privacy practices with respect to medical information about you;
- Make sure that medical information that identifies you is kept private; and
- Follow the terms of the notice that is currently in effect.
How We May Use and Disclose Medical Information about You
The following categories describe different ways we use and disclose medical information. For each category we will explain what we mean and try to give some examples. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.
Treatment. We may use and disclose medical information about you to provide you with medical treatment or services. For example, a specialist we may refer you to may need to know about a treatment you received at our office in order to coordinate other treatments you are receiving.
Payment. We may use and disclose medical information about you so that the treatment and services you receive at our office may be billed and payment may be collected from you, an insurance company or a third party. For example, we may need to give your health plan information about services you received at our office so your health plan will pay us or reimburse you for the services.
Health Care Operations. We may use and disclose medical information about you for our office operations. These uses and disclosures are necessary to run our office and make sure that all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you.
Appointment reminders. We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at our office.
Treatment alternatives. We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.
Health-related benefits and services. We may use and disclose medical information to tell you about health-related benefits or services that may be of interest to you.
Individuals involved in your care or payment for your care. We may release medical information about you to a close personal friend or family member who is involved in your medical care or payment for your care, so long as you have not objected and it is reasonable for us to infer that such disclosure is in your best interest.
Special purposes when permitted or required by law. We may disclose medical information about you as for special purposes when permitted or required by law, including the following:
- To avert a serious threat to health or safety against you, the public or another person.
- For public health and administrative oversight activities such as disease control, abuse or neglect reporting, health and vital statistics, audits, investigations, and licensure reviews.
- For organ and tissue donation and transplant to facilitate organ or tissue donation and transplant.
- For research purposes limited information may be disclosed as permitted by law.
- To workers’ compensation or similar programs for the payment benefits for work-related injuries.
- To coroners, medical examiners and funeral directors to identify a deceased person, determine cause of death, or to carry out duties.
- To comply with court orders, judicial proceedings, or other legal processes related to law enforcement, custody of inmates, legal and administrative actions, and criminal activity.
- For U.S. military and veteran reporting regarding members and veterans of the armed forces of U.S. or foreign military.
- For national security and intelligence activities such as protective services for the president and other authorized persons.
- State and other federal laws. We will comply with all applicable state and federal laws. For example, under state law, there are more limits on the disclosure of HIV and aids information. We will continue to abide by all applicable state and federal laws.
Other uses of medical information require an authorization. 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 authorization. If you provide us an authorization to use or disclose medical information about you, you may revoke that authorization, in writing, at any time. If you revoke your authorization, we will no longer use or disclose medical information about you for the reasons covered by the written authorization. You understand that we are unable to take back any disclosures we have already made with your authorization, and that we are required to retain our records of the care that we provide to you.
Your Rights Regarding Medical Information About You
You have many rights with regard to your medical information. If you wish to exercise any of these rights, you must submit your request in writing, unless otherwise noted.
Your right to inspect and copy. You have the right to inspect and copy medical information that may be used to make decisions about your care. We may charge a reasonable fee for the costs of copying, mailing or other supplies associated with your request.
Your right to amend. If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to add a statement. You must provide a reason that supports your request for an amendment.
Your right to an accounting of disclosures. You have the right to request an “accounting of disclosures.” This is a list of certain disclosures we made of medical information about you. Your request must state a time period. We may limit the time period to 6 years. The first list you request within a 12-month period is free. For additional lists, we may charge you for the costs of providing the list.
Your right to request restrictions. You have the right to request a restriction or limitation on the medical information we use or disclose about you. For any services for which you paid out-of-pocket in full, we will honor any request you make to restrict information about those services from your health plan, provided that such release is not necessary for your treatment. In all other circumstances, we are not required by law to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment.
Your right to request confidential communications. You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work or by mail. If we maintain medical information about you in electronic format, you also have the right to obtain a copy of such information in electronic format and to direct us to transmit such information directly to an entity or person clearly, conspicuously, and specifically designated by you. We will not ask you the reason for your request. You may make this request in writing or verbally.
Right to paper copy of this notice. You have the right to a paper copy of this notice. You may ask us to give you a copy of this notice at any time.
Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with us. You may also file a complaint directly with the secretary of the department of health and human services. You will not be penalized in any way for filing a complaint.
Changes To This Notice
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice at our offices and make copies available upon request.
Privacy notice contact information
For questions about this privacy notice, contact: email@example.com