Health Care Privacy Forms
NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION
Law requires the privacy of your health information be maintained and that you are provided this notice of the legal duties and privacy practices with respect to your health information. Other than the uses and disclosures we described below, your health information will not be sold or provided to any outside marketing organization. We must abide by the terms of this notice and we reserve the right to change the terms of this privacy notice. If a change is made, it will apply for all of your health information in our files, and you will be notified in writing.
HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
USES AND DISCLOSURES
Here are examples of use and disclosure of your health care information:
YOUR RIGHT TO LIMIT USES OR DISCLOSURES
You have the right to request that we do not disclose your information to specific individuals, companies, or organizations. Any restrictions should be requested in writing. We are not required to honor these requests. If we agree with your restrictions, the restriction is binding on us.
PERMITTED USES AND DISCLOSURES WITHOUT YOUR CONSENT OR AUTHORIZATION
Under federal law, we are also permitted or required to use or disclose your information without your consent or authorization in the following circumstances:
REVOKING YOUR AUTHORIZATION
You may revoke your authorization to us at any time in writing. There are two circumstances under which we will not be able to honor your revocation request:
We will attempt to accommodate any reasonable written request regarding your contact information that has been provided by you.
AMENDING YOUR HEALTH INFORMATION
You have the right to request that we amend your health information for seven years from the date that the record was created or as long as the information remains in our files. We require a written request to amend your records that includes a valid reason to support the change. We have the right to refuse your request.
INSPECTING/COPYING YOUR HEALTH INFORMATION
You have the right to inspect the your files while in our office and/or have a copy made for you. The information is available up to seven years from the date that the record was created.
Your request to inspect or obtain a copy of the file must be in writing. There will be a charge of $.20 per page copied.
ACCOUNTING OF DISCLOSURES OF YOUR RECORDS
You have the right to request an accounting of any disclosures (not listed below) made of your information for six years prior to the date of your request. The request must be in writing. The accounting will exclude the following disclosures:
Required for your session, to obtain payment for services, to run our practice, and/or made to you.
Necessary to maintain a directory of the individuals in our facility or to individuals involved in your care.
For national security, intelligence purposes, or law enforcement officers.
That were made prior to the effective date of the HIPAA privacy law (April 14, 2003). We will provide the first accounting within a 12-month period without any charge, but any additional requests will be charged a fee. When you make your request we will tell you the amount of the fee and you will have the opportunity to withdraw or modify your request
We cannot control the actions of others to whom we have released your information for further treatment. Information that we use or disclose may be subject to re-disclosure by these individuals/facilities and may no longer be protected by the federal privacy rules.
You may complain to us or to the Secretary for Health and Human Services if you feel that we have violated your privacy rights. We respect your right to file a complaint and will not take any action against you if you file a complaint. Written comments should be addressed to our office address or Secretary for Health and Human Services, 200 Independence Ave. SW, Room 509F, HHH Bldg. Washington, DC 20201. This notice effective as of April 14, 2003. This notice will expire six years after the date upon which the record was created. By signing below, I acknowledge that I was given the opportunity to read and ask questions.