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.
The privacy of your medical information is important to us. You may be aware that U.S. Government regulators established a privacy rule ("HIPAA") governing certain health information. This notice tells you about how this "protected" health information may be used and about certain rights you have.
David Hyman, MD is in charge of privacy matters at our facility. You can contact him at the telephone number on the letterhead for further information or for any questions or concerns.
Use and disclosure of protected information
Federal law provides that we may use your medical information (particularly, that part of which is considered under HIPAA regulations to be "protected medical information") for purposes of your treatment without further specific notice to you or written authorization by you. For instance, if we refer you to another physician, we may provide clinical and/or laboratory information to that physician (subject to any New York laws that may be more stringent concerning genetic and/or infectious disease test results).
Federal law permits us to use your medical information to obtain payment for our services without further specific notice or written authorization by you. For instance, we may be required to provide diagnostic codes, procedure codes, dates of treatment, and sometimes written summaries to your insurer in order to be appropriately reimbursed.
Federal law also provides that we may use your medical information for health care operations without specific notice or written authorization by you. For instance, we may use your information for internal quality assurance and for internal financial purposes.
We may use or disclose your medical information without further notice to you or specific authorization by you in the following circumstances:
Where required by law;
When required for public health purposes;
If required by law to report child abuse;
Where required by a health oversight agency for activities authorized by law, such as the New York State Department of Health;
As required in judicial or administrative proceedings, or for law enforcement purposes;
When required by a coroner or medical examiner;
When permitted by law to a funeral director or for the purposes of organ donation;
Where permitted by law to avert a serious threat to health or safety;
Where permitted by law and required by military authorities, if you are a member of the United States Armed Forces
New York State law provides additional protection for information regarding HIV/AIDS and genetic test results. We will continue to follow New York State law with respect to such information.
We may contact you at your residence, by mail or phone, to remind you of appointments or to provide information about treatment. Unless you instruct us otherwise, we may leave a message for you on any answering device or with any person who answers the phone at your residence, providing we reveal the minimal amount of medical information necessary to accomplish the appropriate notification. You may make reasonable requests for us to use alternative methods of communicating with you in a confidential manner in the space provided at the end of this notice.
Other uses or disclosures of your medical information will be made only with your written authorization. You may revoke any written authorization you have given.
Rights that you have
You have the right to request restrictions on certain of the uses or disclosures described above. Except as stated below, we are not required to agree to such restrictions.
You have the right to inspect and obtain copies of your medical information, for which a reasonable fee may be charged.
You have the right to request amendments to your medical information. Such requests must be in writing and must state the reason for the requested amendment. We will notify you whether we agree or disagree with the requested amendment. If we disagree with any requested amendment, we will further notify you of your rights.
You have the right to request an accounting of any disclosures we make of your medical information, except for: disclosures we make to you, or to carry out treatment, payment or health care operations, or as requested by your written authorization, or as permitted or required under 45 CFR §164.502, or for emergency or notification purposes, or for national security or intelligence purposes as permitted by law, or to correctional facilities or law enforcement officials as permitted by law or for research or public health purposes after being de-identified or limited to remove personally identifiable information or disclosures made before April 14, 2003.
If you have received this notice electronically, you have the right to obtain a paper copy from our office.
Obligations that we have
We are required by law to maintain the privacy of protected health information and to provide individuals with notice of our legal duties and privacy practices.
We are required to abide by the terms of this notice as long as it is currently in effect.
We reserve the right to revise this notice and to make a new notice effective for all protected health information we maintain. Any revised notice will be posted in our facility, and copies will be available there.
If you want to complain about violations of your privacy rights, you have the right to file a complaint with the Secretary of the Department of Health and Human Services of the United States. You may also file a complaint with us. Complaints should be addressed to Dr. David Hyman at the address and telephone number on the letterhead. No retaliatory action will be taken against you for any complaint you may make.
I have received a paper copy of this notice.
|Signature / printed name|| Date
I make the following special request(s) for confidential communications:
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