NOTICE OF PRIVACY PRACTICES & HIPAA RELEASE
Patient Health Information Under Federal Law, your patient health information includes information about your symptoms, test results, diagnosis, treatment, and related medical information. Your health information also includes payment, billing and insurance information.
How we use your Patient Health Information We use health information about you for treatment, to obtain payment, and for healthcare operations, including administrative purposes and evaluation of quality of care that you receive. Under some circumstances, we may be required to use or disclose the information even without your permission.
Examples of Treatment, Payment and Health Care Operations Treatment: We will use and disclose your health information to provide you with medical treatment or services. For example, nurses, physicians, and other members your treatment team will record information in your record and use it to determine the most appropriate course of care. We may also disclose the information to other health care
providers who are participating in your treatment, to pharmacists who are filing your prescriptions. Payment: We will use and disclose your health information for payment purposes. For example, we may need to obtain authorization from your insurance company before providing certain types of treatment. We will submit bills and maintain
records of payments from your health plan. Health Care Operations: We will use and disclose your health information to conduct our standard internal operations, including proper administration of records, evaluation of the quality of treatment, and to assess the care and outcomes of your case and others like it.
Special Uses We may use your information to contact you with appointment reminders. We may also contact you to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you. Other Uses & Disclosures We may use or disclose identifiable health information about you for other reasons, even without your consent. Subject to certain requirements, we are permitted to give out health information without your permission for the following purposes:
Request Restrictions: You may request Required by Law: We may be required by lawrestrictions on certain uses and disclosures of to report Gunshot wounds, suspected abuseyour health information. We are not required or neglect, or similar injuries and events. to agree to such restrictions, but if we do Research: We may use or discloseagree, we must abide by those restrictions. information for approved medical research Also if you have paid for your health care Public Health Activities: As required by law, treatment out-of -pocket and in full, and if you request that we limit disclosure of your we may disclose vital statistics, diseases, information to a health plan for purposes of information related to recalls of dangerous products, and similar information to publicpayment or health care operations, we will health authorities. abide by your request. Judicial and administrative proceedings: Inspect and Obtain Copies: In most cases, We may disclose information in response to you have the right to look at or get a copy of an appropriate subpoena or court order.your health information. There may be a Law enforcement purposes: Subject to certain charge for receiving copies of your health restrictions, we may disclose informationinformation. required by law enforcement officials. Confidential Communications: You may ask Deaths: We may report information regardingus to communicate with you confidentially by, deaths to coroners, medical examiners,for example sending notices to a special funeral directors, and organ donation address, electronic mail, text messaging, or agencies.voicemails. You have the right to request to not receive notifications from the office and Serious threat to health and safety: We may use and disclose information when opt out receiving email, text or phone necessary to prevent a serious threat to your messages, patient communications and to health and safety or the health and safety of remind you of appointments. the public or another person.Amend Information: If you believe that Military and Special Government Functions: information in your record is incorrect, or if If you are a member of the armed forces, we important information is missing you have the may release information as required by right to request that we correct the existing military command authorities. We may alsoinformation or add the missing information. disclose information to correctional institutionsAccounting Disclosures: You may request a list of instances where we have disclosed or national security purposes. Workers Compensation: We may release health information about you for reasons other information about your workers compensation than treatment, payment, or health care or similar programs providing benefits foroperations. work-related injuries or illness. In any otherOur Legal Duty situation, we will ask for your written We are required by law to protect and authorization before using or disclosing any maintain the privacy of your health identifiable health information about you. If information, to provide this Notice about or you choose to sign an authorization to legal duties and privacy practices, regarding disclose information, you can later revoke that protected health information, and to abide by authorization to stop any future uses and the terms of Notice currently in effect. disclosures.Changes in Privacy Protection Individual Rights We may change our policies at any time. You have the following rights with regard to Before we make a significant change in our your health information. Please contact the policies, we will change our Notice and post person listed below to obtain the appropriate the new Notice in the waiting area and each form for exercising theses rights. examination room. You can also request a copy of our Notice at any time. For more information about our privacy practices contact the office and request to speak to the Release of Information Officer.
I authorize Samuel N. Marcus, M.D. Inc. to use/disclose medical and/or billing information to the following authorized representative. All patients must complete this section for us to provide access to account (including billing and a appointments If this section is not filled out we will not provide such access to anyone other than the pa ient. This isnotfor release of information to another physician. Please be aware that the patient is still responsible for any account balances that result from actions of designated representative (for example: no show fee