PRIVACY NOTICE

THIS NOTICE DESCRIBES HOW YOUR MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THAT INFORMATION.

PLEASE REVIEW THIS NOTICE CAREFULLY.

This practice is committed to maintaining the privacy of your protected health information (“PHI”), which includes information about your medical condition and the care and treatment you receive from the practice. This notice details how your PHI may be used and disclosed to third parties to carry out your treatment, payment for your treatment, health care operations of the practice, and for other purposes permitted or required by law. This notice also details your rights regarding your PHI.

USE OR DISCLOSURE OF PHI

1. The practice may use and/or disclose your PHI for treatment, payment for your treatment, and health care operations of the practice. The following are examples of the types of uses and/or disclosures of your PHI that may occur. These examples are not meant to include all possible types of use and/or disclosure.

(a) Treatment – In order to provide, coordinate and manage your health care, the practice will provide your PHI to those health care professionals, whether on the practice’s staff or not, directly involved in your care so that they may understand your medical condition and needs, and provide advice or treatment (e.g., a specialist or laboratory). For example, a physician treating you for a condition such as arthritis may need to know what medications have been prescribed for you by the practice’s physicians.

(b) Payment – In order to get paid for services provided to you, the practice will provide your PHI, directly or through a billing service, to appropriate third party payors, pursuant to their billing and payment requirements. For example, the practice may need to provide your health insurance carrier or, if you are over 62, the Medicare program with information about health care services that you received from the practice so that the practice can be properly reimbursed. The practice may also need to tell your insurance plan about the need to hospitalize you so that the insurance plan can determine whether or not it will pay for the expense.

(c) Health Care Operations – In order for the practice to operate in accordance with applicable law and insurance requirements and in order for the practice to continue to provide quality and efficient care, it may be necessary for the practice to compile, use and/or disclose your PHI in order to evaluate the performance of the practice’s personnel in providing care to you.

AUTHORIZATION NOT REQUIRED

1. In addition to treatment, payment and health care operations, the practice may use and/or disclose your PHI, without a written authorization from you, in the following instances:

(a) De-Identified Information – Your PHI is altered so that it does not identify you and, even without your name, cannot be used to identify you.

(b) Business Associate – To a business associate, which is someone who the practice contracts with to provide a service necessary for your treatment, payment for your treatment and health care operations (e.g., billing service or transcription service). The practice will obtain satisfactory written assurance, in accordance with applicable law, that the business associate will appropriately safeguard your PHI.

(c) Personal Representative – To a person who, under applicable law, has the authority to represent you in making decisions related to your health care.

(d) Public Health Activities – Such activities include, for example, information collected by a public health authority, as authorized by law, to prevent or control disease, injury or disability. This includes reports of child abuse or neglect.

(e) Federal Drug Administration - If required by the food and drug administration to report adverse events, product defects or problems or biological product deviation, or to track products, or to enable product recalls, repairs or replacements, or to conduct post marketing surveillance.

(f) Abuse, Neglect or Domestic Violence – To a government authority if the practice is required by law to make such disclosure. If the practice is authorized by law to make such a disclosure, it will do so if it believes that the disclosure is necessary to prevent serious harm or if the practice believes that you have been the victim of abuse, neglect or domestic violence. Any such disclosure will be made in accordance with the requirements of law, which may also involve notice to you of the disclosure.

(g) Health Oversight Activities – Such activities, which must be required by law, involve government agencies involved in oversight activities that relate to the health care system, government benefits programs, government regulatory programs and civil rights law. Those activities include, for example, criminal investigations, audits, disciplinary actions, or general oversight activities relating to the community’s health care system.

(h) Judicial and Administrative Proceedings – for example, the practice may be required to disclose your PHI in response to a court order or a lawfully issued subpoena.

(i) Law Enforcement Purposes – In certain instances, your PHI may have t be disclosed t a law enforcement official for law enforcement purposes. Law enforcement purposes include: (1) complying with a legal process (i.e., subpoena) or as required by law; (2) information for identification and location purposes (e.g., suspect or missing person); (3) information regarding a person who is or is suspected to be a crime victim; (4) in situation where the death of an individual may have resulted from criminal conduct; (5) in the event of a crime accruing on the premises of the practice; and (6) a medical emergency (not on the practice’s premises) has occurred, and it appears that a crime has occurred.

(j) Coroner or Medical Examiner – The practice may disclose your PHI to a coroner or medical examiner for the purpose of identifying you or determining your cause of death, or to a funeral director as permitted by law as necessary to carry out its duties.

(k) Organ, Eye or Tissue Donation – If you are an organ donor, the practice may disclose your PHI to the entity to whom you have agreed to donate your organs

(l) Research – If the practice is involved in research activities, your PHI may be used, but such use is subject to numerous governmental requirements intended to protect the privacy of your PHI such as approval of the research by an institutional review board and the requirement that protocols must be followed.

(m) Avert a Threat to Health or Safety – The practice may disclose your PHI if it believes that such disclosures is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the disclosure is to an individual who is reason able to prevent or lessen the threat.

(n) Specialized Government Functions – When the appropriate conditions apply, the practice may use PHI of individuals who are armed forces personnel: (1) for activities deemed necessary by appropriate military command authorities; (2) for the purpose of a determination by the Department of Veteran Affairs of eligibility for benefits; or (3) to a foreign military authority if you are a member of that foreign military service. The practice may also disclose your PHI to authorized federal officials for conducting national security and intelligence activities including the provision of protective services to the president or others legally authorized.

(o) Inmates – The practice may disclose your PHI to a correctional institution or a law enforcement official if you are an inmate of that correctional facility and your PHI is necessary to proved care and treatment to you o r is necessary for the health and safety of other individuals or inmates.

(p) Workers’ Compensation – If you are involved in a Workers’ Compensation claim, the practice may be required to disclose your PHI to an individual or entity that is part of the Workers’ Compensation system.

(q) Disaster Relief Efforts – The practice may use or disclose your PHI to a public or private entity authorized to assist in disaster relief effort.

(r) Required by Law – If otherwise required by law, but such use or disclosure will be made in compliance with the law and limited to the requirements of the law.

AUTHORIZATION
Uses and/or disclosures, other than those described above, will be made only with your written authorization, which you may revoke at any time.

SIGN-IN-SHEET
The practice may use a sign-in sheet at the registration desk. The practice may also call your name in the waiting room when your physician is ready to see you.

APPOINTMENT REMINDER
The practice may, from time to time, contact you to provide appointment reminders.