Treatment, Payment and Health Care Operations

The most common reasons why we use of disclose your health information is for treatment, payment, or health car operation. Examples of how we disclose information for treatment include referring you to another doctor or clinic or requesting information from other health care providers. In some cases, we must disclose your health information, such as a diagnostic or treatment code, to a third-party payer to receive payment, or so that you may receive payment from the payer. We routinely use your health information inside our office for these purposes without any special permission. We will generally get your written authorization before disclosing any information to any entity outside our office. In some situations, the law the either allows or requires us to use or disclose your health information without your permission.

Some of these situations include:

• Making appointments or sending reminders about appointments.
• Disclosing information to a close friend, family member, or caregiver about treatment or payment options.
• Mandates from state or federal law that certain health information be reported for a specific purpose.
• Use or disclosure of information to prevent a serious threat to health or safety.
• Use or disclosure of information to “business associates” such as HMOs, insurance companies or materials suppliers who perform health care operations for us and who commit to respect the privacy of your health.

At times, we may request that you sign a written authorization form before we use or disclose your health information to an outside party. In certain cases, we may also ask you to communicate this information directly to another individual or entity. You have the right to inspect and obtain a copy of your health records. Reasonable administrative, copying, and mailing fees may apply. You may also request a written accounting of disclosures, detailing when, how, and to whom your health information has been released, if applicable. Reasonable administrative, copying, and mailing fees may apply. If you believe any part of your health information is inaccurate or incomplete, you have the right to submit a written request for correction or amendment.

If you believe your privacy rights have been violated, you may file a written complaint with our office or with the U.S. Department of Health & Human Services at 200 Independence Avenue SW, Washington, DC 20201. There will be no retaliation for filing a complaint.

We reserve the right to amend this Notice of Privacy Practices at any time, as permitted by law. Any changes will apply to all health information we maintain and will be made available upon request. I have read, understand, and agree to the above Privacy Practices Notice and authorize the release of information as stated.