Hipaa Notice Of Privacy Practices Template printable pdf download

HIPAA Notice of Privacy Practices

Steven D. Goodrich, M.D.

621 S. New Ballas, Suite 585A

St. Louis, MO 63141

Phone: (314) 251-6478

Fax: (314) 251-5817

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 is NOT an authorization. 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 or related health care

services. Protected health information may also include photographic documentation of the patient by the doctor and any

images given to the doctor depicting specified symptoms.

Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff and others 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 bill, 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, 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. 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 and

inform you about treatment alternatives or other health-related benefits and services that may be of interest to you. If we

use or disclose your protected health information for fundraising activities, we will provide you the choice to opt out of

those activities. You may also choose to opt back in.

We may use or disclose your protected health information in the following situations with 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 or law enforcement; coroners; funeral

directors; organ donation; research; criminal activity; military activity and national security; workers’ compensation;

inmates; and other required uses and disclosures. Under the law, we must make disclosures to you upon your request and

Hipaa Notice Of Privacy Practices Template