Effective: September 23, 2013 (EXAMPLE ONLY)
This notice describes how medical information about you may be used and disclosed and how you can access this information. Please review it carefully. If you have any questions, please get in touch with our office.
We are required by law to:
- Maintain the privacy of your protected health information;
- Give you this notice of our duties and privacy practices regarding health information about you;
- Follow the terms of our notice that is currently in effect.
How We May Use and Disclose Your Health Information
The following are the ways we may use and disclose health information that identifies you (Health Information or PHI). Except for the following purposes, we will use and disclose health information only with your written permission. You may revoke such consent at any time by writing to us and stating that you wish to revoke the consent you previously gave us.
Treatment: We may use and disclose health information for your treatment and to provide you with treatment-related healthcare services. For example, we may disclose health information to doctors, nurses, technicians, or other personnel, including people outside our office, who are involved in your medical care and need the information to provide you with medical care.
Payment: We may use and disclose health information to bill and receive payment from you, an insurance company, or a third party for the treatment and services you received. For example, we may give your health plan information so that they will pay for your treatment. However, if you pay for your services yourself (e.g., out-of-pocket and without any third-party contribution or billing), we will not disclose health information to a health plan if you instruct us not to do so.
HealthCare Operations: We may use and disclose health information for healthcare operations. These uses and disclosures are necessary to ensure that all our patients receive quality care and operate and manage our office. For example, we may use and disclose information to ensure your care is of the highest quality. Subject to the exception above, if you pay for your care yourself, we also may share information with other entities that have a relationship with you (for example, your health plan) for their healthcare operations.
Appointment Reminders, Treatment Alternatives, and Health Related Benefits and Services: We may use and disclose health information to contact you and to remind you that you have an appointment with us. We also may use and disclose health information to tell you about treatment alternatives or health-related benefits and services that may interest you. We will not, however, send you communications about health-related or non-health-related products or services that a third party subsidizes without your authorization.
Individuals Involved in Your Care or Payment for Your Care: When appropriate, we may share health information with someone involved in your medical care or payment for your care, such as your family or a close friend. We also may notify your family about your location or general condition or disclose such information to an entity assisting in a disaster relief effort.
Research: Under certain circumstances, we may use and disclose health information for research. For example, a research project may involve comparing the health of patients who received one treatment to those who received another for the same condition. The project will be approved before we use or disclose health information for research. Even without approval, we may permit researchers to look at records to help them identify patients who may be included in their research project or for other similar purposes, as long as they do not remove or take a copy of any health information.
Fundraising and Marketing: We may use health information for fundraising communications, but you can opt out of receiving such communications. Except for the exceptions detailed above, uses and disclosures of health information for marketing purposes and disclosures that constitute a sale of health information require your authorization if we receive any financial remuneration from a third party in exchange for making the communication. We must advise you that we are receiving payment.
Other Uses: You may authorize other uses and disclosures of health information not contained in this notice.
As Required by Law: We will disclose health information when required by federal, state, or local law.
To Avert a Serious Threat to Health or Safety: We may use and disclose health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Disclosures, however, will be made only to someone who may help prevent the threat.
Business Associates: We may disclose health information to our business associates who perform functions on our behalf or provide us with services if the data is necessary for such functions or services. For example, we may use another company to perform billing services. All of our business associates are obligated to protect the privacy of your information. They are not allowed to use or disclose any information other than as specified in our contract.
Organ and Tissue Donation: If you are an organ donor, we may use or release health information to organizations that handle organ procurement or other entities engaged in procurement, banking, or transportation of organs, eyes, or tissues to facilitate organ, eye, or tissue donation; and transplantation.
Military and Veterans: If you are an armed forces member, we may release health information as military command authorities require. We also may release health information to the appropriate foreign military authority if you are a foreign military member.
Workers’ Compensation: We may release health information for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.
Public Health Risks: We may disclose health information for public health activities. These activities generally include disclosures to prevent or control disease, injury, or disability; report births and deaths; report child abuse or neglect; report reactions to medications or problems with products; notify people of recalls of products they may be using; a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition; and the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only make this disclosure if you agree or when required or authorized by law.
Health Oversight Activities: We may disclose health information to a health oversight agency for legally authorized activities. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the healthcare system, government programs, and compliance with civil rights laws.
Lawsuits: If you are involved in a lawsuit or a dispute, we may disclose health information in response to a court or administrative order. We also may disclose health information in response to a subpoena, discovery request, or other lawful process by someone involved in the dispute, but only if we have made efforts to tell you about the request or obtain an order protecting the information requested.
Law Enforcement: We may release health information if asked by a law enforcement official if the information is:
(1) In response to a court order, subpoena, warrant, summons, or similar process;
(2) Limited information to identify or locate a suspect, fugitive, material witness, or missing person;
(3) About the victim of a crime even if, under certain minimal circumstances, we are unable to obtain the person’s agreement;
(4) About a death we believe may be the result of criminal conduct;
(5) About criminal conduct on our premises; and
(6) In an emergency to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime.
Coroners, Medical Examiners, and Funeral Directors: We may release health information to a coroner or medical examiner, which may be necessary, for example, to identify a deceased person or determine the cause of death. We also may release health information to funeral directors as necessary for their duties.
National Security and Intelligence Activities: We may release health information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.
Protective Services for the President and Others: We may disclose health information to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state or conduct special investigations.
Inmates or Individuals in Custody: Suppose you are an inmate of a correctional institution or under the custody of a law enforcement official. In that case, we may release health information to the correctional institution or law enforcement official. This release would be, if necessary:
(1) For the institution to provide you with healthcare;
(2) To protect your health and safety or the health and safety of others; or
(3) The safety and security of the correctional institution.
You have the following rights regarding health information we have about you:
Right to Inspect and Copy: You have the right to inspect and copy health information that healthcare providers may use to make decisions about your care or payment for your care, including medical and billing records, excluding psychotherapy notes. You must request that our office inspect and copy this health information in writing.
Right to Amend: If you feel our health information is incorrect or incomplete, 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 our office. To request an amendment, you must request our office in writing.
Right to an Accounting of Disclosures: You can request a list of certain disclosures we made of health information for purposes other than treatment, payment, and healthcare operations or for which you provided written authorization.
To request an accounting of disclosures, you must request our office in writing.
Right to Request Restrictions: You can request a restriction or limitation on the health information we use or disclose for treatment, payment, or healthcare operations. You also have the right to request a limit on the health information we disclose to someone involved in your care or the payment for your care, like a family member or friend. For example, ask that we not share information about a particular diagnosis or treatment with your spouse. To request a restriction, you must request our office in writing. We are not required to agree to all such requests. If we agree, we will comply with your request unless the information is needed to provide emergency treatment.
Right to Request Confidential Communication: You have the right to request that we communicate with you about medical matters in a certain way or at a specific location. For example, you can ask that we only contact you by mail or at work. To request confidential communication, you must request our office in writing. Your request must specify how or where we can contact you. We will accommodate reasonable requests.
Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice. Please ask us to give you a copy of this notice anytime. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy. You may obtain a copy of this notice in our office.
To obtain a paper copy of this notice, please request it in writing.
Right to Electronic Records: You have the right to receive a copy of your electronic health records in electronic form.
Right to Breach Notification: We will notify you if a breach of privacy results in the disclosure, misuse, or insecurity of your health information.
Changes to This Notice
We reserve the right to change this notice and make the new notice apply to the health information we already have and any information we receive in the future. We will post a copy of our current notice at our office. The notice will contain the effective date on the first page, in the top right-hand corner.
If you believe we have violated your privacy rights, you may file a complaint with our office or the Department of Health and Human Services Secretary. You must make all complaints in writing. You will not be penalized for filing a complaint.
Privacy Contact Officer: Name of Officer Here