Notice of Privacy Practices (Brief Version)

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY.

Our commitment to your privacy

Our practice is dedicated to maintaining the privacy of your personal health information as part of providing professional care.  We are also required by law to keep your information private.  These laws are complicated, but we must give you this important information. This is the shorter version of the attached, full, legally required notice of privacy practices.  Please let us know if you have any questions or concerns.

How we use and disclose your protected health information with your consent

We may use the information collected about you mainly to provide you with the treatment, to arrange payment for services, and for some other business activities that are called, in the law, health care operations.  After you have read this notice we will ask you to sign a consent form to let us use and share your information in these ways.  If you do not consent and sign this form, we cannot treat you.  If we want to use or send, share, or release your information for other purposes, we will discuss this with you and ask you to sign an authorization form to allow this. 

Disclosing your health information without your consent

There are some times when the laws require us to use or share your information.  For example:

1. When there is a serious threat to your or another’s health and safety or to the public.  We will only share information with persons who are able to help prevent or reduce the threat. 
2. When we are required to do so by lawsuits and other legal or court proceedings.
3. If a law enforcement official requires us to do so.
4. For workers’ compensation and similar benefit programs.

There are some other rare situations.  They are described in the longer version of the notice of privacy practices.

Your rights regarding your health information

1. You can ask us to communicate with you in a particular way or at a certain place that is more private for you.  For example, you can ask us to call you at home, and not at work, to schedule or cancel an appointment.  We will try our best to do as you ask.
2. You can ask us to limit what we tell people involved in your care or the payment for your care, such as family members and friends.
3. You have the right to look at the health information we have about you, such as your medical and billing records.  You can get a copy of these records, but we may charge you for it.
4. If you believe that the information in your records is incorrect or missing something important, you can ask us to make additions to your records to correct the situation.  You have to make this request in writing and tell us the reasons you want to make the changes.
5. You have the right to a copy of this notice.  If we change this notice, we will provide you with the new version.
6. You have the right to file a complaint if you believe your privacy rights have been violated.  You can file a complaint with us and the Secretary of the U.S. Department of Health and Human Services.  All complaints must be in writing.  Filing a complaint will not change the health care we provide to you in any way.  Also, you may have other rights that are granted to you by the laws of our stated, and these may be the same as or different from the rights described above.  We will be happy to discuss these situations with you now or as they arise.  If you have any questions regarding this notice or our health information privacy, please let me know.

The effective date of this notice is June 23, 2020.

This form has been modified from The Paper Office. Copyright 2008 by Edward L. Zuckerman.