Notice of Privacy Practices
Privacy Officer: Brianna Staten
Revised Date: 12/31/2020
This notice describes how medical information about you may be used, disclosed and how you can get access to this
information. Please review carefully. We care about our patient’s privacy and strive to protect the confidentiality
of your medical information. Federal legislation requires that we issue this official notice of our privacy practices.
You have the right to the confidentiality of your medical information, and this practice is required by law to
maintain the privacy of that protected health information. This practice is required to abide by the terms of the
Notice of Privacy Practices currently in effect, and to provide notice of its legal duties and privacy practices
with respect to protect health information.
Any health care professional authorized to enter this information into your medical record, employees, staff and other
personnel at this practice who may need access to your information must abide by this notice. All subsidiaries, business
associates (ex: a billing service), sites and locations of this practice may share medical information with each other
for treatment, payment or health care operations described in this notice. Except where treatment is involved, only the
minimum necessary information needed to accomplish the task will be shared.
The following categories describe different ways that we may use and disclose medical information without your specific
consent or authorization. Examples are provided for each category of uses or disclosures (not all possible uses and
disclosures are listed):
- Treatment: We may use medical information about you to provide you with medical treatment or services.
Example: In treating you for a specific condition, we may need to know if you have allergies that could influence
which medications we prescribe for the treatment process.
- Payment: We may use and disclose medical information about you so that the treatment and services you receive
from us may be billed and payment may be collected from you, an insurance company, or third party. Example: We may
need to send your protected health information, such as your name, address, office visit and codes identifying
your diagnosis and treatment to your insurance company for payment.
- Health Care Operations: We may use and disclose medical information about you for your health care
operations to assure that you receive quality care. Example: We may use medical information to review our
treatment and services and evaluate the performance of our staff in caring for you.
Other Uses or Disclosures That Can Be Made Without Consent/Authorization:
- As required during an investigation by law enforcement agencies
- To avert a serious threat to public health or safety
- As required by military command authorities for their medical records
- To workers compensation or similar programs for processing of claims
- In response to a legal proceeding
- To a coroner or medical examiner for identification of a body
- To a correctional institute or law enforcement official, if an inmate
- As required by US Food and Drug Administration (FDA)
- Other healthcare providers treatment activities
- Other covered entities and providers payment activities
- Other covered entities healthcare operations activities (to the extent permitted under HIPAA)
- Uses and disclosures required by law
- Uses and disclosures in domestic violence or neglect situations
- Health oversight activities & Other public health activities
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.
Uses and Disclosures of Protected Health Information Requiring Your Written Authorization:
Other uses and disclosures of medical information not covered by this notice or the laws that apply
to us will be made only with your written authorization. If you give us authorization to use or disclose
medical information about you, you may revoke that authorization, in writing, at any time. If you revoke
your authorization, we will thereafter no longer use or disclose medical information about you for the
reasons covered by your written authorization. You understand that we are unable to take back any disclosures
we have already made with your authorization, and that we are required to retain our records of the care we
have provided. If you believe your privacy rights have been violated, you may file a complaint with the privacy
officer at this practice or with the secretary of the Department of Health and Human Services. All complaints
must be submitted in writing. You will not be penalized or discriminated against for filing a complaint.
Patient Rights
- You have the right to request restrictions or limitation on the medical information we use or disclose
about you for treatment, payment, or health care operations or to someone who is involved in your care or
the payment for your care. We are not required to agree to your request. If we do agree, we will comply with
your request unless the information is needed to provide you with emergency treatment. To request restrictions,
you must submit your request in writing to the privacy officer at this practice. In your request, you must tell
us what information you want to limit.
- You have the right to request how we should send communications to you about medical matters, and where you would
like those communications sent. To request confidential communications, you must make your request to the privacy
officer at this practice. We will accommodate all reasonable requests. Your request must specify how or where you
wish to be contacted. We reserve the right to deny a request if it imposes an unreasonable burden on the practice.
- You have the right to inspect and copy medical information that may be used to make decisions about your care.
Usually this includes medical and billing records but does not include; psychotherapy notes, information compiled
for use in a civil, criminal or administrative action or proceeding, and protected health information to which
access is prohibited by law. To inspect and copy medical information that may be used to make decisions without you,
you must submit your request in writing to the privacy officer at this practice. If you request a copy of the information,
we reserve the right to charge a fee for the costs of copying, mailing or other supplies associated with your request.
We may deny your request to inspect and copy in certain very limited circumstances. If you are denied access to medical
information, you may request your denial to be reviewed. Another licensed health care professional chosen by this practice
will review your request and the denial. The person conducting the review will not be the person who denied your request.
We will comply with the outcome of the review.
- You have the right to request an amendment for as long as the information is kept. If you feel that medical information
we have about you is incorrect or incomplete, you may ask us to amend the information. To request an amendment, your
request must be made in writing and submitted to the privacy officer at this practice. In addition, you must provide a
reason that supports your 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. In addition, we may deny your request your request if the information was not created by
us, is not part of the medical information kept at this practice, is not part of the information which you would be
permitted to inspect and copy, or which you would be permitted to inspect and copy, or which we deem to be accurate and
complete. If we deny your request for amendment, you have the right to file a statement if you disagree with our office.
We may prepare a rebuttal to your statement and will provide you with a copy of any such rebuttal. Statements of disagreement
and any corresponding rebuttals will be kept on file and sent out with any future authorized requests for information
pertaining to the appropriate portion of your record.
- You have the right to request a list of the disclosures we made of medical information about you. To request this list,
you must submit your request to the privacy officer of this practice. Your request must state the time period for which
you want to receive a list of disclosures that is within a six-year time frame from requested date. Your list should
indicate in what form you want the list (ex: paper or electronic). The first list you request within a 12-month period
will be free. For additional lists, we reserve the right to charge you for cost of providing the list.
- You have a right to a paper copy of this notice at any time. Even if you have agreed to receive this notice
electronically, you are still entitled to a paper copy of the current notice.
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical
information we already have about you, as well as any information we receive in the future. We will post a copy of the
current notice with the effective date in the upper right corner of the first page.