Hipaa Notice Of Privacy Practices Form - Missouri

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HIPAA Notice of Privacy Practices
Susan Carter-O’Shea D.D.S., P.C.
1504 A Highway, Suite A
Liberty, MO 64068
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND
HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY.
This Notice of Privacy Practice describes how we may use and disclose your protected health information (PHI) to
carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted by law. It also
describes you rights to access and control you protected health information. “Protected health information” is
information about you, including demographic information, that may identify you and that relates to your past, present
or future physical or mental health or condition and related health care services.
1.
Uses and Disclosures of Protected Health Information
Uses and Disclosures of Protected Health Information
Your protected health information may be used and disclosed by your physician, our office staff and others outside
of our office that are involved in your care and treatment for the purpose of providing health care services to you,
to pay your health care bills, to support the operation of the physician’s practice, and any other use required by
law.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage you
health care and any related services. This includes the coordination or management of your health care with a
third party. For example, we would disclose you protected health information, as necessary, to a home health
agency that provides care to you. For example, your protected health information may be provided to a physician
to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat
you.
Payment: Your protected health information will be used, as needed, to obtain payment for your health care
services. For example obtaining approval for a hospital stay may require that your relevant protected health
information be disclosed to the health plan to obtain approval for the hospital admission.
Healthcare Operations: We may use or disclose, as needed, your protected health information in order to
support the business activities, training of medical students, licensing, and conducting or arranging for other
business activities. For example, we may disclose your protected health information to medical school students
that see patients in our office. In addition, we may use a sign-in sheet at the registration desk where you will be
asked to sign your name and indicate you physician. We may also call you by name in the waiting room when
your physician is ready to see you. We may use or disclose your protected health information, as necessary, to
contact you to remind you of your appointment.
We may use or disclose your protected health information in the following situations without your authorization.
These situations include: as Required by Law, Public Health issues required by law, Communicable Diseases:
Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceedings: Law
Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity
and National Security: Workers’ Compensation: Inmates: Required Uses and Disclosures: Under the law, we must
make disclosures to you and when required by the Secretary of the Department of Health and Human Services to
investigate or determine our compliance with the requirements of Section 164.500.
Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization, or
opportunity to object unless required by law.
You may revoke the authorization, at any time, in writing, except to the extent that your physician or the
physician’s practice has taken action in reliance on the use or disclosure indicated in the authorization.
Your Rights
Following is a statement of your rights with respect to your protected health information.

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