Hipaa Notice Of Privacy Practices Template


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 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


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