Notice of Privacy Practices


This Notice of Privacy Practices is provided to you as a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). HIPAA is about individual privacy, and you should read this document carefully. It describes how we may use and disclose your protected health information for purposes of treatment, payment or health care operations, 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 (PHI) is information about you, including demographic information, that may identify you and that relates to your past, present or future physical condition and related health care services, or payment for health care services.


We are required to follow the terms of this Notice of Privacy Practices. We understand that medical information about you and your health is personal. We are committed to protecting health information about you. In the course of conducting our medical practice business, we will create records regarding you and the treatment and services we provide to you. Your health record is the physical property of the healthcare practitioner or facility that compiled it, but the content is about you and therefore belongs to you.

We are required by law to:

  • Ensure protected health information that identifies you is kept private;
  • Give you this notice of our legal duties and privacy practices regarding your protected health information; and
  • Follow the terms of the notice that is currently in effect.


The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or change the terms of this Notice of Privacy Practices at any time. Any revision or amendment to this notice will be effective for all of your records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. When the Notice of Privacy Practices has been revised, our practice will post a copy of the revised Notice in our offices in a visible location. You may request a copy of our most current Notice at any time.


The following categories describe the different ways in which we may use and disclose your PHI without your authorization. For each category of use or disclosure, an explanation follows to explain what we mean and to present some examples. Not every use or disclosure in a category is listed.

Treatment: Our practice may use your protected health information, including your individually identifiable health information (IIHI), to treat you. For example, we may ask you to have laboratory tests (such as blood or urine 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, our doctors and nurses - may use or disclose your PHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your PHI to others who may assist in your care, such as your spouse, children or parents. Finally, we may also disclose your PHI to other healthcare providers for purposes related to your treatment.

Payment: Our practice may use and disclose your PHI in order to bill and collect payment for the services and items you may receive form us. For example, we may contact your health insurer to certify that you are eligible for benefits (and for what range of benefits), and we may provide your insurer with details regarding your treatment to determine if your insurer will cover, or pay for, your treatment. We also may use and disclose your PHI to obtain payment from third parties that may be responsible for such costs, such as family members. Also, we may use your PHI to bill you directly for services and items. We may disclose your PHI to other healthcare providers and entities to assist in their billing and collection efforts.

Health Care Operations: Our practice may use and disclose your PHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your PHI to evaluate the quality of care you received from us, or to conduct cost-management and business planning activities for our practice. We may disclose your PHI to other health care providers and entities to assist in their health care operations. We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. For example, your name and address will be used to send you a newsletter about the services we offer, health resources, and other information related to your health.

Appointment Reminders: Our practice may use and disclose your PHI to contact you and remind you of an appointment. However, it is our policy to get your written authorization to leave messages.

Treatment Options: Our practice may use and disclose your PHI to inform you of potential treatment options or alternatives.

Health-Related Benefits and Services: Our practice may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you.

Personal Representatives: A person is your personal representative only if they have authority by law to act on your behalf in making decisions related to health care. They then must be given the same consideration as you and we may disclose your protected health information to them. We may require your personal representative to produce evidence of his/her authority to act on your behalf. We may not recognize him/her if we have a reasonable belief that treating such person as your personal representative could endanger you and we decide that it is not in your best interest to treat them as your personal representative. In addition, in the event of your death, an executor, administrator, or other person authorized under the law to act on behalf of you or your estate will be treated as your personal representative. You may also be a personal representative by law for another individual in your family, such as a minor child or an incapacitated adult. Minor children may have some rights as specified in state consent laws that relate directly to minors.

Individuals Involved in Your Care: Unless you object, we may disclose to a member of your family, a relative, a close friend, or any other person you identify, your protected health information that directly relates to that person's involvement in your health care or payment related to your health care. If you are not present, we may disclose your medical information based on our professional judgment or whether the disclosure would be in your best interest. In the same way, we may also disclose your medical information in the event of incapacity or in an emergency.

Business Associates: Some of your health information may be subject to disclosure through contract services to assist this office in providing health care. For example, it may be necessary to obtain specialized assistance to process certain laboratory tests or radiology images. To protect your health information, we require these Business Associates to follow the same standards held by this office through terms detailed in a written agreement.


Our practice may also use and disclose your protected health information in the following situations without your authorization. These situations include the following:

Disclosures Required By Law: Our practice will use and disclose your health information when we are required to do so by federal, state or local law.

Public Health Risks: Our practice is required by law to disclose health information to public health and/or legal authorities charged with tracking reports of birth and morbidity. This office is further required by law to report communicable disease, injury or disability.

Abuse and Neglect: We may disclose your protected health information to a public health authority that is authorized by law to receive reports of abuse or neglect. In addition, we may disclose your protected health information to a governmental authority or agency authorized to receive such information, if we believe that you have been a victim of abuse, neglect or domestic violence to the governmental entity or agency authorized to receive such information. In this case, the disclosure will be made consistent with the requirements of applicable federal and state laws.

Health Oversight Activities: Our practice may disclose your PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example, investigations, inspections, audits, surveys, licensure and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

Legal Proceedings: We may disclose protected health information during any judicial or administrative proceeding, in response to an order of a court, or administrative tribunal, if such disclosure is expressly authorized by order. We may disclose protected health information in response to a subpoena, discovery request or other lawful process, if the party seeking the information satisfactorily assures us that reasonable efforts have been made to either notify you of the request or obtain a protective order.

Law enforcement: We may disclose protected health information for law enforcement purposes. These law enforcement procedures include:

  • Legal orders, warrants, subpoenas, or summons;
  • Information for identifying and locating a suspect, fugitive, material witness, or missing person;
  • Circumstances pertaining to victims of a crime;
  • Suspicion that death occurred as a result of criminal conduct

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 job.

Organ 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.

Research: Our practice may use and disclose your PHI for research purposes in certain limited circumstances. We will obtain your written authorization to use your PHI for research purposes except when an Institutional Review Board or Privacy Board has determined that the waiver of your authorization satisfies the following: (i) the use or disclosure involves no more than a minimal risk to your privacy based on the following: (A) an adequate plan to protect the identifiers from improper use and disclosure; (B) an adequate plan to destroy the identifiers at the earliest opportunity consistent with the research (unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law); and (C) adequate written assurances that the PHI will not be re-used or disclosed to any other person or entity (except as required by law) for authorized oversight of the research study, or for other research for which the use or disclosure would otherwise be permitted; (ii) the research could not practicably be conducted without the waiver; and (iii) the research could not practicably be conducted without the access to and use of the PHI.

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. Under these circumstances, we will only make disclosures to person or organization able to help prevent the threat.

Military: Our practice may use and disclose your PHI if you are a member of U.S. or foreign military forces (including veterans) and if required by the appropriate authorities.

National Security: Our practice may use and disclose your PHI to federal officials for intelligence and national security activities authorized by law. We also may disclose your PHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.

Inmates: Our practice may use and disclose your PHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety and security of the institution, and/or (c) to protect your health and safety or the health and safety of other individuals.

Workers Compensation: Our practice may use and disclose your PHI to comply with laws relating to workers' compensation or other similar programs established by law.


Uses and disclosures other than those in this notice will be made only with your written authorization. You may revoke an authorization at any time in writing. If you revoke an authorization, it will not affect any action taken or any information released by us prior to receiving and processing your request to revoke the authorization. Please make these requests in writing to our Privacy Official.

Following is a statement of your rights with respect to your protected health information and a brief description of how you may exercise these rights.

Right to 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. For instance, you may ask that we contact you at home, rather than at work. In order to request a type of confidential communication, you must make a written request to our Privacy Official specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.

Right to Request Restrictions: You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree with your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, emergencies, or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing to our Privacy Official. Your request must describe in a clear and concise fashion:
  (a) the information you wish restricted;
  (b) (whether you are requesting to limit our practice's use, disclosure or both;
  (c) and to whom you want the restrictions to apply.

You may revoke a restriction at any time in writing. We may also terminate our agreement to restriction and would contact you if this situation should occur. Right of Access to Inspect and Copy: You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing records. You may not inspect or copy the following records: psychotherapy notes; information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information. You must submit your request in writing to the Medical Records Department, in order to inspect and/or 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. In most cases, we will provide the requested information within 30 days if the information is maintained on site or within 60 days if the information is maintained offsite. When a decision to deny access has been made, you may have the right to have this decision reviewed in some circumstances.

Right to Amend: You may ask 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. To request an amendment, your request must be made in writing and submitted to ourPrivacy Official. You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, 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 which 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. In most cases, we will act upon your request within 60 days. If we deny your request to amend, 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.

Right to Receive an Accounting of Disclosures: You may request in writing to obtain an accounting of disclosures. This right applies to disclosures we have made for purposes not related to treatment, payment or healthcare operations as described in this Notice of Privacy Practices. It excludes disclosures we may have made to you, to family members or friends involved in your care, to a personal representative, or to disclosures you have specifically authorized. You have the right to receive an accounting of disclosures that occur after April 14, 2003, and for a specific period of time up to six years. You may also request a shorter specific time frame. The first list you request within a 12-month period is free of charge, but our practice may charge you for additional lists within the same 12-month period. Our practice will notify you of the costs involved with any additional requests, and you may choose to withdraw your request before you incur any costs.

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. To obtain a paper copy of this notice, contact our office.

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. To file a complaint with our practice, contact our Privacy Official. All complaints must be submitted in writing. You will not be penalized for filing a complaint.