Example of uses of your health information for treatment purposes:

 A nurse obtains treatment information about you and records it in a health record. During the course of your treatment, the doctor determines a need to consult with another specialist in the area. The doctor will share the information with such specialists and obtain input.

Example of use of your health information for payment purposes:

We submit a request for payment to your health insurance company. The health insurance company requests information from us regarding medical care given. We will provide information to them about you and the care given. 

Example of Use of your Information for Health Care Operations:

We obtain services from our insurers or other business associates such a quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal services, and insurance. We will share information about you with such insurers or other business associates as necessary to obtain these services.

Your Health Information Rights:

The health record we maintain and billing records are the physical property of the practice. The information in it, however, belongs to you. You have a right to: 

• Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our office. We are not required to grant the request but we will comply with any request granted;
• -Request that you be allowed to inspect and copy you health record and billing record-you may exercise this right by delivering the request in writing to our office; 
• Appeal a denial of access to you protected health information except in certain circumstances; 
• Request that your health care record be amended to correct incomplete or incorrect information by delivering a written request to our office;
• File a statement of disagreement if your amendment  is denied, and require that the request for amendment and any denial be attached in all future disclosures of your protected health information;
• Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a written request to our office. An accounting will not include internal uses of information for treatment, payment, or operations, disclosure made to you or made at your request, or disclosures made to family members or friends in the course of providing care;
• Request that communication of your health information be made by alternative means or at an alternative location by delivering the request in writing to our office; and, 
• Revoke authorizations that you made previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office

If you want to exercise any of the above rights, please contact [insert name of designated staff member, phone number or address], in person or in writing, during normal hours. S[he] will provide you with assistance on the steps to take to exercise your rights.

Our responsibilities:

The practice is required to:

• Maintain the privacy of you health information as required by law;
• Provide you with a notice of our duties and privacy practices as to the information we collect and maintain about you;
• Abide by the terms of this Notice;
• Notify you if we cannot accommodate a requested restriction or request; and 
• Accommodate your reasonable requests regarding methods to communicate health information with you.

We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our :Notice: or by visiting our office and picking up a copy. 

To Request Information or File a Complaint

If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact [insert name, title, and telephone number of internal contact person].

Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to [list internal staff member]. You may also file a complaint by mailing it or e-mailing it to the Secretary of Health and Human Services whose street address and email address is [insert street and e-mail addresses].

• We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services (HHS) as a condition of receiving treatment from the practice. 
• We cannot, and will not, retaliate against you for filing a complaint with the Secretary.

Other disclosures and Uses

Notification

Unless you object, we may use or disclose your protected health information to notify, or assis in notifying, a family member, personal representative, or other person responsible for your care, about your location, and about your general condition, or you rdeath. 

Communication with Family

Using our best judgment , we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your care or in payment for such care if you do no tobject or in a n emergency. 

Food and Drug Administration (FDA)

We may disclose to the FDA your protected health information relating to adverse events with respect to products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements. 

Workers Compensation

If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation. 

Public Health

As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability. 

Abuse & Neglect

We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.

Correctional Institutions:

If you are an inmate of a correctional institution, we may disclose to the institution, or its agents, your protected health information necessary for your health and the health and safety of other individuals 

Law Enforcement

We may disclose your protected health information for law enforcement purposed as required by law, such as when required by a court order, or in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement. 

Health Oversight

Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities.

Judicial/Administrative Proceedings 

We may disclose your protected health information in the course of any judicial or administrative proceeding as allied or required by law, with your consent, or as directed by a proper court order.

Other Uses

Other uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law or with written authorization and you may revoke the authorization as previously provided. 

Website 

If we maintain a website that provides information about our entity, this Notice will be on the website. 

Effective Date: [Insert effective date of the Notice]

I,________________, hereby acknowledge that I have received a copy of this practice’s Notice of Privacy Practices. I have been given the opportunity to ask any questions I may have regarding this Notice.