The following is a Notice of Privacy Practices and Patient Rights at this Clinic; we are required by law to provide you with this information. We apologize for the inconvenience and thank you for allowing us to stay in compliance with the law by acknowledging the following. Please direct any complaints regarding this form to our HIPAA Privacy Officer in person or telephonically.
Your protected health information (PHI) is information about you, including demographic data, that may identify you, and that relates to your past or future physical and mental health condition and related health care services. Your PHI may be used and disclosed by your physician, office staff and others outside our office staff that are involved in your care 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 uses required by federal law.
We will use and disclose your PHI 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 (e.g., data forwarded to another physician who is managing your treatment). Your PHI will be used as needed to obtain payment for your health care services. We may disclose, as needed, your PHI in order to support the business activities of your physician’s practice. These activities include, but are not limited to, quality assessments, employee review training, licensing, marketing and fundraising activities, and conducting or arranging other business activities (e.g., sign-in sheets at front desk or using your PHI to contact you for appointment reminders).
We may use or disclose your PHI in the following situations without 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 director; organ donations; research, criminal investigation; military activity; national security; workers compensation; and inmates required uses and disclosures. Under law, we must make disclosures to you and when required by the U.S. Department of Health and Human Services, if it wants to see that we’re complying with federal privacy law.
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 the physician’s practice has taken an action in reliance on the use or disclosure indicated in the authorization.
You have the right to inspect and copy your PHI under federal law. You may not inspect or copy the following records: psychotherapy notes compiled in reasonable anticipation of or use in a civil, criminal or administrative action or proceeding, and PHI that is subject to law that prohibits access to PHI.
You have the right to request a restriction of your PHI from a specific purpose or individuals. Your request must state the specific restriction and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request if the physician believes it is in your best interest to permit the use and disclosure of your PHI. In this instance, PHI will not be restricted, and you then have the right to another health care professional.
You have the right to request to receive confidential communications from us by alternate means or an alternate location. You have the right to receive a paper copy of this notice from us upon request, even if you have agreed to receive this notice alternatively.
You have the right to have your physician amend your PHI. If your request is denied, you may 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 changes to the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw your request, as provided in this notice.
You may complain to the U.S. Department of Health and Human Services if you believe your privacy rights have been violated by us. You may also file a complaint with us by notifying our Privacy Officer, who is Lizette Lopez, Director of Human Resources, at (623) 440-8576; we will not retaliate against you for filing a complaint.