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.
Allowed Uses and Disclosures of Your Medical Information:
- Treatment – such as ordering diagnostic tests, contacting other health care providers (ex: PCP), communicating
with your pharmacy, etc.
- Payment – such as submitting billing information to your insurance company or making disclosures to consumer
reporting agencies (limited to specific identifying information about the individual, his or her payment history,
and identifying information about the covered entity).
- Health Care Operations – such as quality assurance reviews, coordination of care, or eligibility verification.
- Public Health Activities – such as child abuse or neglect.
In addition to the above, your medical information may be used or disclosed when emergency treatment is necessary;
when we are required by law to treat you, we attempt to obtain consent, and are unable to do so; when we are unable
to obtain consent due to substantial communication barriers and consent for treatment is implied under the
circumstances; or when we have created or received the information in treating an inmate.
You have a right to:
- Request restriction on certain uses and disclosures, however, we are not required to agree to any restriction.
- Receive confidential communications from us, upon written request.
- Inspect and request copies of your medical information.
- Request to amend incorrect or incomplete medical information.
- Receive an accounting of any disclosures made, upon written request.
- Receive a paper copy of this notice upon request or review our entire policy.
We are responsible for:
- Maintaining the privacy of your medical information.
- Providing you this notice and obtaining your written acknowledgement.
- Abiding by the terms of this notice.
- Providing written notice of any change to this notice.
Complaints: You may complain to us or to the Health & Human Services secretary if you believe that your privacy has
been violated. If you wish to file a complaint with us, please provide the office manager with a written notice of how
you believe we violated your privacy. All notices received will be investigated and reviewed by our director. We will
respond to all notices within two (2) weeks of receipt, and we will not retaliate for any allegations you make. We have a
form you can request to complete.
Authorizations: Upon your authorization, we may disclose your medical information to a requesting entity, such as an
attorney, another insurance company (applying for life insurance), or a relative. You may revoke any authorization you
make at any time, except to the extent that it was already relied on.
Patient Contact: We need to contact you to provide test results, appointment reminders, treatment information, or for
patient satisfaction surveys. We typically communicate by phone or email. If you would like to request an alternative communication method, please ask to speak with the office manager.
To obtain information, contact our office manager at 863-578-8633 or firstname.lastname@example.org.