Hipaa Notice Of Privacy Practices Form printable pdf download

HIPPA AGREEMENT

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED

AND DISCLOSED AND HOW YOU CAN GET ACESS TO THIS INFORMATION. PLEASE

REVIEW IT CAREFULLY.

information (PHI)

This Notice of privacy practices describes how we may use and disclose your protected health

to carry out

operations (TPO)

treatment, payment or health care

and for other purpose that are permitted or required by law. It also

describes your right 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 condition and related health care services.

Use 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.

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 thee waiting room when your physician is

ready to see you, we may use or disclose your protected health information, as necessary, to contact you of your

appointment.

We may use or disclose your protected health information in the following situations with out your authorization. These

situations include: as: Required By Law, Public Health issues as 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 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 this authorization

, at any time, in writing, except to the extent that your physician or physician’s

practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights

Following is a statement of your rights with the respect to your protected health information.

You have the right to Inspect and copy your protected health information.

Under federal law, however,

you may not inspect or copy the following: psychotherapy notes; information compiled 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.

Hipaa Notice Of Privacy Practices Form

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