HIPAA Notice of Privacy Practices


This Notice of Privacy Practices describes how we may use and disclose your protected health information (PHI)
to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or
required by law. It also describes your rights to access and control your protected health information.
“Protected health information” is information about you, including demographic information, that my identify
you and that relates to your past present or future physical or mental health or condition and related health
care services.

1. Uses and Disclosures of Protected Health Information

Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your physician, our office staff and others
outside of our office that are involved in your care and treatment for the purpose of providing health care
services to you, to pay your health care bills to support the operation of the physician’s practice, and any other
use required by law.


We will use and disclose your protected health information to provide, coordinate, or manage your
health care and any related services. This includes the coordination and management of your health care with
a third party. For example, we would disclose your protected health information as necessary, to a home health
agency that provides care to you. For example, your protected health information may be provided to a
physician to whom you have been referred to ensure that the physician has the necessary information to
diagnose or treat you.


Your protected health information will be used, as needed, to obtain payment for your health care
services. For example, obtaining approval for a hospital stay may require that your relevant protected health
information be disclosed to the health plan to obtain approval for the hospital admission.

Healthcare Operations:

Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to
support the business activities of your physician’s practice. These activities include, but are not limited to,
quality assessment activities, employee review activities, training of medical students, licensing, and
conducting, arranging for other business activities. For example, we may disclose your protected health
information to medical school students that see patients at our office. In addition, we may use a sign-in sheet at
the registration desk where you will be asked to sign your name and indicate your physician. We may also call
you by name in the waiting room when your physician is ready to see you. We may use or disclose your
protected health information, as necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your
authorization. These situations include: as Required By Law, Public Health issues as required by law,
Communicable Diseases: Heath Oversight: Abuse or Neglect: Food and Drug Administration requirements:
Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal
Activity: Military Activity and National Security: Workers’ Compensation: Inmates: Required Uses and
Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the
Department of Health and Human Services to investigate or determine our compliance with the requirements of
Section 164.500.

Other Permitted and Required Uses and Disclosures Will be Made Only with Your Consent, Authorization or Opportunity to Object unless required by law.

You may revoke this authorization, at any time, in writing, except to the extent that your physician or the
physician’s practice has taken an action I reliance on the use or disclosure indicated in the authorization.

Your Rights:

Following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information. Under federal law; however, you
may not inspect or copy the following records: psychotherapy notes; information compiled in a reasonable
anticipation of, or use in a civil, criminal, or administrative action or proceeding and protected health
information that is subject to law that prohibited access to protected health information.

You have the right to request a restriction of your protected health information. This means you may ask us not
to use or disclose any part of your protected health information for the purposes of treatment, payment or
healthcare operations. You may also request that any part of your protected health information not be
disclosed to family members or friends who may be involved in your care or for notification purposes as
described in the Notice of Privacy Practices. Your request must state the specific restriction requested and to
whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If physician believes it is in your
best interest to permit use and disclosure of your protected health information, your protected health
information will not be restricted. You then have the right to use another Healthcare Professional.

You have the right to request to receive confidential communication from us by alternative means or at an
alternative location. You have the right to obtain a paper copy of this notice from us. Upon request, even if you
have agreed to accept this notice alternatively i.e., electronically.

You may have the right to have your physician amend your protected health information. If we deny your
request for amendment, you have the right to file a statement of disagreement with us and we may prepare a
rebuttal to your statement and will provide you with a copy of any such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected
health information

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then
have the right to object or withdraw as provided in this notice.


You may complain to us or to the Secretary of Health and Human Services. If you believe your privacy rights
have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint.
We will not retaliate against you for filing a complaint.

This notice was published and becomes effective on/or before April 14. 2003.

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties
and privacy practices with respect to protected health information. If you have any objections to this form
please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number.

Signature below is only acknowledgement that you have received this Notice of our Private Practices.

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