Hipaa Notice Of Privacy Practices Template (Page 2 of 3) in pdf

when required by the Secretary of the Department of Health and Human Services to investigate or determine our

compliance with the requirements of Section 164.500.

Other permitted required uses and disclosures will be made only with your consent, authorization or opportunity to

object unless required by law. Without your authorization, we are expressly prohibited to use or disclose your protected

health information for marketing purposes. We may not sell your protected health information without your authorization.

We may not use or disclose most psychotherapy notes contained in your protected health information that contains genetic

information that will be used for underwriting purposes.

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 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 (fees may apply). Pursuant to your written

request, you have the right to inspect or copy your protected health information whether in paper or electronic format.

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

compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding; protected health

information that is subject to law that prohibits access to protected health information; and information that is related to

medical research in which you have agreed to participate, information whose disclosure may result in harm or injury to

you or to another person, or information that was obtained under a promise of confidentiality.

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

use or disclose any part of you 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 your requested restriction except if you request that the physician not disclose protected health

information to your health plan with respect to healthcare for which you paid in full out of pocket.

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

interest to permit use and disclosure of your protected health information, you 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. You have the right to obtain a paper copy of this notice from us, upon request, even if you have

agreed to accept this notice alternatively, i.e. electronically.

You may have the right to have your physician amend your protected health information. If we deny your request for

amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement

and will provide you with a copy of any such rebuttal.

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

information. You have the right to receive an accounting of disclosures, paper or electronic, except for disclosures:

pursuant to an authorization for purposes of treatment, payment, healthcare operations; required by law, that occurred prior

to April 14, 2003, or six years prior to the date of the request.

You have the right to receive notice of a breach. We will notify you if your unsecured protected health information has

been breached.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right

to object or withdraw as provided in this notice.

Hipaa Notice Of Privacy Practices Template Page 2