NOTICE OF PRIVACY PRACTICES (MEDICAL) ‘THS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATICN. PLEASE REVIEW IT CAREFULLY. “Tho Healey Insurance Portabilly & Accountablty Act of 1906 ("HIPAA i a federal program that requires that al medical records and otrerindvdualy Kentiabe heath information used or discosed by usin any for, whether elecuonicaly, 0 paper, o ray, are kept propery confuerta. This Ac ives you, the pelt, significant new rights to understand and orto! how you health information fs used. "HIPAA provides ‘nails for covered ents that misuse persona health information, ‘Asrequired by "HIPAA, we have prepared this explanation of how we are required to matin the privacy of {your heath informaton and how we may use and decoes your heath information We may use and csclose your medical records ony foreach ofthe folowing purposes: treatment, payment ‘and healt eae operations. ‘Treatment means providing, cocrdnating or managing heath care ard related services by one or ‘more heen care providers. An ecarple ofthis would Incude apsical examination. Payment means such activites as chaining reimbursrran! or sovices,corfrming coverage, bling ‘orcolecton activites, anc utization ravi. An example ofthis would be sending abil for your Wt to your insurance compary for payment. Health care operations include the business aspocts of running our practice, such as conducting ‘ualty assessmentand improvemert actives, aditng lunctions, cost-management analysis, and ‘customer serves. An exarpl would be an inoral qualty esessert review. ‘We may also create and dstrbute de-identfie heath information by remeving al references individually ‘genta leormaton, ‘We may contact you to provide appointment reminders or information ebout teatnentatematves or other health-elated benefts anc sevicos hal may be ot inarest fo ye. Any oer usas and disclosures wl be made only with your writan authorizatton. You ray revoke such ‘uthotzaton in writhg and we are required to honor and abide by that writen raques, excepto the extent that we Rave already taken acions relying on yourauhotizaion ‘Yau havethe folowing rights with respect to your protected heath infomation, which you can exercise by resenting a writen request tothe Privacy Officer: © The rghtto aquest retricions cn cotsn uses and clcoeures of pretactad neh infrmatio, Inetudng these reletedo disclosures to family members, other relatives, cso persona ands, any cher person icentied by you. We are, however, nol required io agen te a requested restriction. Ite 30 agree to aresincton, we must abide by unless you agree In wraing to remove “The rghtto reasonable requests to receive conidental communications of protected heath information from us by altemative mears o:ataltematve locations. © Therohtto inspect and copy your protected health information. “The rghtto amend your protected health iformaton, © The rohtto receive an accounting o sclosures of protected healt formato. ‘The rghtto obtain a paper copy of this notice rom us upon request We are required by aw trainin the privacy of your protected heath infomation and to provide you with noice cf ou egal Gules a privacy practices wih espec: to proteced heath information. “This notceis effective as of 20___andwe are requiredto abide bythe terms 0} ‘ne Notice of Privacy Practices carenty Ww efect We resewve the ight fo change te trms cf our Notice ct Privacy Practices and tomato the new notice provisions efetive fr all protected hosith infermaton that wo raintain. We wil pos an you may request « witton copy of a revised Notice af Privacy Practices ror ths ofc. ‘Youhave rceuras if you fel that your prvacy protections hare been vieatod. You have the right oie tion corepiaint with our ofc, or wih the Departmen ot Health & Human Services, Offea of Civ Fights ‘about volations ofthe provisions ofthis natioe or the poles and precedures cf our otce. We will ot etait against you fring a complaint. Ploese cortact us for mare infomation: For more information about HIPAA rte fe a complaint ‘TheU.S. Departmen! ot Heath & Human Services Office ef Cv Rights 200 independance Averve, SW. Washington, D.C. 20001 (202) 619-0257 ‘oll Fre: 1-877-696-6775