Hipaa Notice Of Privacy Practices Form printable pdf download

HIPAA Notice of Privacy Practices

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THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED

AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices 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 or required by law. It also describes your rights to access

and control your 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 Healthy 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 your 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 your

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. This may include

certain activities that your health insurance plan may undertake before it approves or pays for the health care services we recommend for you

such as; making a determination of eligibility or coverage for insurance benefits, reviewing services provided to you for medical necessity

and undertaking utilization review activities. 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 of

your physician’s practice. These activities include, but are not limited to, quality assessment activities, employee review 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 at 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 your 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 situation without your authorization . These situations include: as

Required By Law, Public Health issues as required by law, Communicable Diseases: Health Oversight: Abuse or Neglects: Food and Drug

Administration requirement: 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 requirement of Sections 164.500.

We will share your protected health information with third party “business associates” that perform various activities (e.g., billing,

transcription services) for the practice. Whenever an arrangement between our office and a business associated involves the use or disclosure

of your protected health information we will have a written contract that contains terms that will protect the privacy of your protected health

information.

We may use or disclose your protected health information as necessary to provide you with information about treatment alternatives or other

health-related benefits and services that may be of interest to you. We may also use and disclose your protected health information for other

marketing activities. For example, your name and address may be used to send you information about products or services that we believe

may be beneficial to you. You may contact our Privacy Contact to request that these materials not be sent to you.

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 this authorization, at any time, in writing, except to the extent that your physician or the physician’s practice has taken an

Hipaa Notice Of Privacy Practices Form

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