A. OUR COMMITMENT TO YOUR PRIVACY

Our practice is dedicated to maintaining the privacy of your Protected Health Information (PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that identifies you and to provide you with this notice of our legal duties and our privacy practices.

The terms of this notice apply to all records containing your PHI. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your records that we maintain. A copy of our current Notice will be posted in our offices. You may request a copy of our most current Notice at any time.

B. WE ARE PERMITTED TO USE AND DISCLOSE YOUR PHI IN THE FOLLOWING WAYS:

1. Treatment. Our practice may use and disclose your PHI to treat you. For example, we may ask you to have laboratory tests (such as blood tests), and we may use the results to help us reach a diagnosis. We might use your PHI in order to write a prescription for you, or we might disclose your PHI to a pharmacy when we order a prescription for you. Many of the people who work for our practice – including, but not limited to, doctors and nurses – may use or disclose your PHI in order to treat you or to assist others in your treatment.

2. Payment. Our practice may use and disclose your PHI in order to bill and collect payment for the services and items you may receive from us. For example, we may contact your health insurer to certify that you are eligible for benefits and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment.

3. Health Care Operations. Our practice may use and disclose your PHI to operate our business. For example we may use and disclose your information to evaluate the quality of care you received from us or to conduct business planning activities for our practice.

C. WE ARE PERMITTED TO AND MAY BE REQUIRED TO USE AND DISCLOSURE YOUR PHI IN CERTAIN SPECIAL CIRCUMSTANCES

1. Disclosures Required By Law. Our practice will use and disclose your PHI when we are required to do so by federal, state, or local law, including health oversight activities, court or administrative orders or similar legal proceedings.

2. Public Health Risks. Our practice may disclose your PHI to public health authorities who are authorized to collect information for such purposes as maintaining vital records; preventing or controlling disease, injury, or disability; or notifying a person regarding potential exposure to a communicable disease.

3. Serious Threats to Health or Safety. Our practice may use and disclose your PHI when necessary to reduce or prevent a serious threat to your health and safety or the health and safety of another individual or the public.

4. Deceased Patients. Our practice may release PHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information in order for funeral directors to perform their jobs.

5. Organ and Tissue Donation. Our practice may release your PHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are an organ donor.

6. Workers’ Compensation. Our practice may release your PHI for workers’ compensation and similar programs.

Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described in the authorization.

The practice may contact you or your authorized representatives (see authorization form attached) to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. The practice will routinely contact patients via telephone at home and/or work, or via mail at home, and, unless otherwise requested, may leave messages on the appropriate voice mail or answering service regarding appointments, test results, etc. All mailings will be stamped Personal & Confidential.

D. YOUR RIGHTS REGARDING YOUR PHI

1. Confidential Communications. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. Our practice will accommodate reasonable requests.

2. Requesting Restrictions. You have the right to request a restriction on our use or disclosure of your PHI for treatment, payment, or health care operations. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.

3. Inspection and Copies. You have the right to inspect and obtain a copy of your PHI. Our practice may charge a fee for the costs of copying, mailing, labor, and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial.

4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. You must provide us with a reason that supports your request for amendment. We may deny your request if you ask us to amend information that is in our opinion: a) accurate and complete; b) not part of the PHI kept by or for the practice; c) not part of the PHI that you would be permitted to inspect and copy; or d) not created by our practice, unless the individual or entity that created the information is not available to amend the information.

5. Accounting of Disclosures. You have the right to request an “accounting of disclosures.” This is a list of disclosures our practice has made of your PHI other than for treatment, payment or operations purposes.

6. Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time.

7. Right to File a Complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

If you have any questions regarding this notice or would like to exercise any of your rights under this notice, you may contact: