PRIVACY PRACTICE / HIPPA
It has always been my policy to protect your confidentiality. A federal regulation requires that you have a written and detailed explanation of when and how your personal health information may be used or disclosed.
HOW WE USE & DISCLOSE PROTECTED HEALTH INFORMATION (PHI) ABOUT YOU:
TREATMENT:
Health information may be disclosed for referrals in order to plan, provide or coordinate your care with other health care providers.
PAYMENT:
Your PHI may be used or disclosed to bill & collect payment for services rendered.
HEALTH CARE OPERATIONS:
Information may be used for operational, administrative and quality assurance activities.
OTHER USES & DISCLOSURES THAT CAN BE MADE WITHOUT YOUR WRITTEN AUTHORIZATION:
The following are categories for which I may never have a reason to make disclosure, and you have the right to agree or object to these disclosures. You may revoke an authorization in writing at any time.
INDIVIDUALS INVOLVED IN YOUR CARE OR PAYMENT FOR YOUR CARE:
Food & Drug Administration (FDA)
Worker’s Compensation
As Required by Law, as in response to subpoena or court orderJudicial & Administrative Proceedings
Coroners, Medical Examiners, Funeral Directors
To Avert a Serious Threat to Health or Safety
Organ or Tissue Procurement Organizations
National Security, Intelligence Activities, Protective Services for the President and Others
Public Health
Law Enforcement
Health Oversight Activities Research
Victims of Abuse or Neglect
Military & Veterans
YOUR HEALTH INFORMATION RIGHTS:
You have the right to request additional restrictions or disclosures of PHI via written request. I am not required to agree to restrictions that are legally required or necessary to administer business.
You have the right to inspect & obtain a copy of PHI under most circumstances. You must submit your request in writing. You may request an amendment of PHI if you feel it is incomplete or incorrect. You must submit your request in writing. I may decline request for an amendment in some cases.
You have the right to receive an accounting of disclosures of PHI made after April 14, 2003 for most purposes other than treatment, payment, or health care operations. The time period may not be longer than six years & may not include dates before April 14, 2003.
You may request communications of PHI by alternative means or at alternative locations. You must submit your request in writing & inform me how or where you would like to be contacted. All reasonable efforts will be made to avoid incidental disclosures.
COMPLAINTS:
If you feel your privacy rights have been violated, you may file a complaint with me or with the secretary of the United states Department of Health & Human services. There will not be retaliation for filing a complaint.
By electronically signing below I attest to reading, understanding and agreeing to the preceding Privacy Practices and HIPPA Statement:
