Hipaa Notice Of Privacy Practices Form (Page 2 of 2) in pdf

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.

You have the right to inspect and copy your protected health information. This means you may inspect and obtain a copy of protected

health information about you that is contained in a designated record set for as long as we maintain the protected health information. A

“designated record set” contains medical and billing records and any other records that your physician and the practice use for making

decisions about you. Under federal law, however, you may not inspect or copy the following records; psychotherapy notes; information

complied in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information

that is subject to law that prohibits access to protected health information.

You have the right to request a restriction or your protected health information. This means you may ask us not to use or disclose any

part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part

of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification

purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want

the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If physician believes it is in your best interest to permit use and

disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use

another Healthcare Professional.

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. We

will accommodate reasonable requests. We may also condition this accommodation by asking you for information as to how payment will be

handled or specification of an alternative address or other method of contact. We will not request an explanation for you as to the basis for

the request. Please make this request in writing to our Privacy Contact.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. This

right applies to disclosures for purposes other than treatment, payment or healthcare operations as described in this Notice of Privacy

Practices.

We are required to abide by the terms of this Notice of Privacy Practices. We may change the terms of our notice at any time. The new

notice will be effective for all protected health information that we maintain at this time. Upon your request, we will provide you with any

revised Notice of Privacy Practices by calling the office and requesting that a revised copy be sent to you in the mail or asking for one at the

time of your next appointment.

Complaints

You may complain to us or to the Office of Civil Rights if you believe your privacy rights have been violated by us . You may file a

complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint. You may

obtain the address of the OCR Regional Manager, Denver, CO, from our privacy officer.

Clinic Name and Phone #

This notice was published and becomes effective on/or before April 14, 2007.

We are required by law to maintain the privacy of, and provide individuals with this notice of our legal duties and privacy practices with

respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in

person or by phone at Clinic Phone #.

Signature below is only acknowledgement that you have received this Notice of our Privacy Practices:

Print Name:______________________________Signature:____________________________________ Date:___________

Hipaa Notice Of Privacy Practices Form Page 2