Patient Information Template (Page 4 of 8) in pdf

Law Enforcement. We may release IIHI if asked to do so by a law enforcement official:

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Regarding a crime victim in certain situations, if we are unable to obtain the person’s agreement

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Concerning a death we believe has resulted from criminal conduct

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Regarding criminal conduct at our offices

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In response to a warrant, summons, court order, subpoena or similar legal process

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To identify/locate a suspect, material witness, fugitive or missing person

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In an emergency, to report a crime (including the location or victim(s) of the crime, or the description, identity or location of the perpetrator)

Serious Threats to Health or Safety. Our practice may use and disclose your IIHI 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 a person

or organization able to help prevent the threat.

Military. Our practice may disclose your IIHI 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 disclose your IIHI to federal officials for intelligence and national security activities authorized by law. We

also may disclose your IIHI to federal officials in order to protect the President, other officials or foreign heads of state, or to conduct investigations.

Inmates. Our practice may disclose your IIHI 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 release your IIHI for workers’ compensation and similar programs.

YOUR RIGHTS REGARDING YOUR IIHI:

You have the following rights regarding the IIHI that we maintain about you:

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 work. In order to request a type of

confidential communications, you must make a written request to the address above, Attn: Medical Records Custodian. Specify the requested

method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need a reason

for your request.

Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your IIHI for treatment, payment or health care

operations. Additionally, you have the right to request that we restrict our disclosure of your IIHI 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 to your request, however, if we do agree, we are

bound by our agreement, except when otherwise required by law, in emergencies, or when the information is necessary to treat you. In order to

request a restriction in our use or disclosure of your IIHI, you must make your request in writing to the address above, Attn: Medical Records

Custodian. 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; and

(c)

to whom you want the limits to apply.

Inspection and Copies. You have the right to inspect and obtain a copy of the IIHI that may be used to make decisions about you, including

patient medical records and billing records, but not including psychotherapy notes. You must submit your request in writing to the address above,

Attn: Medical Records Custodian. In order to inspect and/or obtain a copy of your IIHI. Our practice will charge a fee for the costs of copying,

mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited

circumstances; however, you may request a review of our denial. Another licensed healthcare professional chosen by us will conduct the review.

Amendment. You may ask us 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 the

address above, Attn: Medical Records Custodian. 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 IIHI kept by or for the practice; (c) not part of the IIHI

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.

Accounting of Disclosures. All of our patients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of

certain non-routine disclosures our practice has made of your IIHI for non-treatment or operations purposes. Use of your IIHI as part of the routine

patient care in our practice is not required to be documented. For example, the doctor sharing information with the nurse; or the billing department

using your information to file your insurance claim. In order to obtain an accounting of disclosures, you must submit your request in writing to the

address above, Attn: Medical Records Custodian. All requests for an “accounting of disclosures” must state a time period, which may not be

longer than six (6) years from the date of disclosure, and may not include dates before April 14, 2003. 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 l2-month period. Our practice will notify you of the

costs involved with additional requests, and you may 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 anytime.

Right to Files 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 in writing:

Gwinnett OB/GYN Associates, P.C., ATTN: Privacy Officer, 1700 Tree Lane Road, Suite 290, Snellville, GA 30078

All complaints must be submitted in writing. You will not be penalized for filing a complaint

Right to Provide an Authorization for Other Uses and Disclosures. Our practice will obtain your written authorization for uses and disclosures

that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the use and disclosure of your

IHII may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your IHII for the reasons

described in the authorization. Please note, we are required to retain records of your care. Again, if you have any questions regarding this notice

or our health information privacy policies, please contact the Office Manager or Practice Administrator at (770) 972-0330.

Patient Information Template Page 4

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