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HIPAA Privacy Policy

Notice of Privacy Practice

Effective Date: 04/01/2005

We must create a record of the care and services you receive at this office to treat you and to comply with certain legal requirements. This notice applies to all of the records of your care generated by our office, whether made by your personal doctor or by other personnel within our office and advises you about the obligations regarding the use and disclosure of medical information. It describes your rights and our obligations regarding the use and disclosure of medical information. We are required by law to make sure medical information that identifies you is kept private, to give you this notice of our privacy practices with respect to medical information, and to follow the terms described in this notice.

How we may use and disclose medical information about you

Treatment – We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to doctors, nurses, technicians, medical students, or other office personnel who are involved in your medical care and treatment. Different departments of the office may share medical information about you in order to coordinate your care. We may disclose medical information about you to people outside the office who may be involved in you medical care after you leave the office, such as family members, clergy or others we may rely upon or ask to assist us in caring for you.

Payment – We may use and disclose medical information about you so that the treatment and services may be billed to and payment may be collected from you or your insurance company or other responsible third party. We may also tell your health insurance plan about treatment you are going to receive in order to obtain prior approval or to determine whether your plan will cover the treatment.

Health Care Options – We may use and disclose medical information about you for office operations. These uses and disclosures are necessary to run the office and make sure all of our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our staff in caring for you. We may disclose medical information to doctors, nurses, technicians, medical students, and other office personnel for review and learning purposes. We may also combine the medical information we have with medical information from other offices to compare how we are doing and see where we can make improvements in the care and services that we offer. We may remove information that identifies you from this set of medical information so others may use it to study health care and health care delivery without learning who the specific patients are.

Appointment Reminders – We may contact you to provide appointment reminders or information about treatment alternatives or other health related benefits and services that may be of interest to you.

Treatment Alternatives – We may use and disclose medical information to tell you about or recommend possible treatment options or alternatives that may be of interest to you. For example, we may use your information to determine whether you qualify for a nutritional counseling program.

Health–Related Benefits and Services – We may use and disclose medical information to tell you about health related benefits or services that might be of interest to you.

Fundraising Activities – We may use medical information about you to contact you in an effort to raise money for disease specific non-profit foundation affiliated with this office and its operations. We may disclose medical information to a non-profit foundation related to the office practice or a specific disease condition so that the foundation may contact you in raising money. We only would release contact information, such as your name, address and phone number and the dates you received treatment or services at this office. If you do not want the office to contact you for fundraising efforts, you must notify in writing.

Ambulatory Surgery Center Registry – We may include certain limited information about you in the ambulatory surgery registry while you are a patient at the ambulatory surgery center. This information may include your name, location in the ambulatory surgery center, your general condition (e.g., fair, stable, etc.) and your religious affiliation. The registry information, except for your religious affiliation, may also be released for people who ask for you by name. Your religious affiliation may be given to a member of the clergy, such as a priest or rabbi, even if they don’t ask for you by name. This is so your family, friends and clergy can visit you in the ambulatory surgery center and generally know how you are doing.

Individuals Involved in Your Care or Payment of Your Care – We may release medical information about you to a friend or family member who is involved in you medical care. We may also give information to someone who helps pay for your care. For example, a babysitter responsible for the care of a child may be provided certain information about the treatment provided to the child. We may also tell your family or friends your condition. In addition, we may disclose medical information about you to an entity assisting in a disaster relief effort so that your family can be notified about your condition, status and location.

Research– Under certain circumstances; we may use and disclose medical information about you for research purposes. For example, a research project may involve comparing the health and recovery of all patients who received one medication to those who have received another, for the same condition. All research projects however, are subject to a special approval process. This process evaluates a proposed research project and its use of medical information, trying to balance the research needs with patients’ need for privacy of their medical information. Before we use or disclose medical information for research, the project will have been approved through the research approval process. We may, however, disclose medical information about you to people preparing to conduct a research project; for example, to help them look for patients with specific medical needs, so long as the people preparing to conduct a research project; for example, to help them look for patients with specific medical needs, so long as the medical information they review does not leave the office. We will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care at the office.

As Required By Law – We will disclose medical information about you when required to do so by federal, state or by local law.

To Avert a Serious Threat to Health or Safety – We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure would only be to someone able to help prevent the threat. Military and

Veterans – If you are a member of the armed forces, we may release medical information about you as required by military command authorities. We may also release medical information about foreign military personnel to the appropriate foreign military authority. If you are a member of the armed forces, we may disclose medical information about you to the Department of Veterans Affairs upon your separation or discharge from the military services. This disclosure is necessary for the Department of Veterans Affairs to determine whether you are eligible for certain benefits.

Workers’ Compensation – We may disclose medical information on you to workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illness.

Public Health Risks – We may disclose medical information about you for public health activities. These activities generally include the following:

• To prevent or control disease, injury or disability;
• To report births and deaths;
• To report reactions to medications or problems with products;
• To notify people of recalls or products they may be using;
• To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition;
• To notify the appropriated government authority if we believe a patient has been a victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree.

Health Oversight Activities– We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities may include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Lawsuits and Disputes – If you are involved in a lawsuit or a dispute, we may disclose medical information about you in response to a court or administrative order. We may also disclose medical information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if required by law or if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement – We may release medical information if requested by a law enforcement official acting pursuant to valid legal authority.

Coroners, Medical Examiners and Funeral Directors – We may release medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release medical information about patients to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities – We may release medical information about you to authorized federal officials for the purpose of determining your own security clearance.

Inmates – If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary (1) for the institution to provide you with health care; (2) to protect your health and safety or the health and safety of others; (3) for the safety and security of the correctional institution.

Your rights regarding medical information

You have the following rights regarding medical information we maintain about you:

Right to Inspect and Copy – You have the right to inspect and copy medical information that may be used to make decisions about your care. To inspect and copy medical information that may be used to make decisions about you, you must submit your request in writing. If you request a copy of the information, we may charge a fee as permitted by state law for the costs of copying, mailing or other supplies associated with your request.

Right to Amend – If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for the office. To request an amendment, your request must be made in writing. In addition, you must provide a reason that supports you request. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. We may also deny your request if you ask us to amend information that was not created by us or if the current record is accurate and complete.

Right to Accounting of Disclosure – Your have the right to request an “accounting of disclosures.” This is a list of the disclosures we made of medical information about you. To request this list or accounting of disclosures, you must submit your request in writing. Your request must state a time-period that may be longer than six years and may not include dated before April 1, 2005. The first list you request within a 12- month period will be free. For additional lists, we may charge you for the cost of providing the list.

Right to Request Restrictions – You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment or health care operations. You have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. To request restrictions, you must make your request in writing. In your request, you must tell us (1) what information you want to limit; (2) whether you want to limit use, disclosure, or both; (3) to whom you want the limits to apply, for example, disclosure to your spouse.

Rights to Request Confidential Communications – You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work, or by mail. To request confidential communications, you must make your request in writing. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

COMPLAINTS – If you believe your privacy rights have been violated, you may file a complaint with the office or Secretary of the Department of Health and Human Services. To file a complaint with the office, contact Mrs. Lauren Blauer or Dr. Christian Guzman. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

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