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Privacy Notice

NOTICE OF PRIVACY PRACTICES
(Effective April 14, 2003)

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.

USES AND DISCLOSES OF YOUR MEDICAL INFORMATION
For Treatments: We may use medical information about you to provide you with medical treatment or services. For Payments: We may use and disclose medical information about you so that the treatments and services you receive at our practice may be billed to and payment may be collected from you, an insurance company, or a third party. For Heath Care Operations: We may use and disclose health information about you for operation of our health care practice. For Individuals Involved in Your Care or Payment of Your Care: We may release medical information about you to a friend of family member who is involved in your medical care. For Health-Related Services and Treatment Alternatives: We may use and disclose health information to tell you about health-related services or recommend possible treatment options or alternatives that may be of interest to you. As Required by Law: We will disclose medical information about you when required to do so by federal, state, or local law. To Avert a Serious Threat to Health or Safety: We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. For Military and Veterans: If you are a member of the armed forces, we may release medical information about you as required by military command authorities. For Workers Compensation: We may release medical information about you for workers’ compensation or similar programs. For Public Health Reasons: We may disclose medical information about you for public health activities. For Health Oversight Activities: We may disclose medical information to a health oversight agency for activities authorized by law. For Lawsuits and  Disputes: If you are involved in a lawsuit or dispute, we may disclose medical information about you in response to a court or administrative order. For Law Enforcement: We may release medical information if asked to do so by law enforcement officials. For Coroners Medical Examiners and Federal Directors: We may release medical information to the coroner or medical examiner. For National Security and Intelligence Activities: We may release medical information about you to authorized federal officers for intelligence, counterintelligence, and other national security activities authorized by law. For Protective Services for the President and Others: We may disclose medical information about you to authorized federal officials so they may provide protection to the President, other authorized persons, or foreign heads of state or to conduct special investigations. For Inmates: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official.

YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION
YOUR RIGHT TO INSPECT AND COPY: To inspect and copy your medical information, you must submit your request in writing. We may deny your request to inspect and copy, in limited circumstances. If you are denied access to medial information, you my request in writing, that the denial be reviewed. Your Right to Amend: If you feel that medical information we have about you is incorrect or incomplete, you may request an amendment in writing. Your request may be denied if you do not include a reason to support the request. Your Right to an Accounting of Disclosures: You have the right to request in writing a list accounting for any disclosures of your medical information we have made, expect for use and disclosures for treatment, payment, and health care operations, as perviously described. Your Rights to Request Restrictions: You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment, or health care operations. We are not required to agree to your request. Your Right to Request Confidential Communications: You have the right to request in writing that we communicate with you about medical matters in a certain way or at a certain location. Your Right to a Paper Copy of This Notice: You have the right to a paper copy of this notice at any time.

CHANGES TO THIS NOTICE: We have the right to change this notice, and will post the current notice in our facility.

COMPLAINTS: If you believe your privacy rights have been violated, you may file a complaint with the practice or with the Secretary of the Department of Health and Human Services.  

OTHER USES OF MEDICAL INFORMATION: Other uses and disclosures of medical information not covered by this notice or the laws that apply to use will be made only with your written permission. If you provide us permission to use or disclose medication information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provide you.

By my signature below I acknowledge receipt of a copy of the Notice of Privacy Practices


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Patient or Personal Representative Signature                     Date