Notice Of Privacy Practices
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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
We are required by law to maintain the privacy of your protected health information, to notify you of our
legal duties and privacy practices concerning your health information, and to notify affected individuals
following a breach of unsecured health information. This Notice summarizes our duties and your rights
concerning your information. Our duties and your rights are set forth more fully in 45 CFR Part 164.
HOW WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION
The following examples describe ways that we may use your protected health information for your
treatment, payments, healthcare operations, etc. but please be advised that not every use or disclosure in
a particular category will be listed.
Treatment: We may use and disclose your protected health information to provide you treatment. This
includes disclosing your protected health information to other medical providers, trainees, therapists,
medical staff, and office staff that are involved in your health care.
For example, your medical provider might need to consult with another provider to coordinate your care.
Also, the office staff may need to use and disclose your protected health information to other individuals
outside of our office such as the pharmacy when a prescription is called in.
Payment: Your protected health information may also be used to obtain payment from an insurance
company or another third party. This may include providing an insurance company your protected health
information for a pre-authorization for a medication we prescribed.
Health Care Operations: We may use or disclose your protected health information in order to operate
this medical practice. These activities include training students, reviewing cases with employees,
utilizing your information to improve the quality of care, and contacting you by telephone, email, or text
to remind you of your appointments.
If we have to share your protected health information to third-party “business associates” such as a
billing service if so, we will have a written contract that contains terms that will protect the privacy of
your protected health information.
We may also use and disclose your protected health information for marketing activities. For example,
we might send you a thank you card in the mail with a coupon for specialized services or products. We
may also send you information about products or services that might be of interest to you. You can
contact us at any point to stop receiving this information.
We will not use or disclose your protected health information for any purpose other than those identified
in this policy without your specific, written authorization. You may give us written authorization to use
your protected health information or to disclose it to anyone for any purpose. You can revoke this
authorization at any time but will not affect the protected health information that was shared while the
authorization was in effect.
Appointment reminders: We may contact you as a reminder that you have an appointment for your
initial visit, follow-up visit, or lab work via text, phone, or email. We normally contact you by telephone
and possibly by email if you have given your email address. You may request to receive confidential
communications of protected health information from us by alternative means or at alternative locations.
We will accommodate a reasonable request.
Others Involved in Your Health Care: We may disclose protected health information about you to
your family members or friends if we obtain your verbal agreement to do so, or if we allow you to object
to such a disclosure and you do not raise an objection. For example, we may assume that if your spouse
or friend is present during your evaluation, we can disclose protected professional information to this
person. If you are unable to agree or object to such a disclosure, we may disclose such information as
necessary if we determine that it is in your best interest based on our professional judgment if there is an
urgent or emergent need.
Research: We will not use or disclose your health information for research purposes unless you
authorize us to do so.
Organ Donation: If you are an organ donor, we may release protected health information to
organizations that handle organ procurement or organ, eye, or tissue transplantation if it is necessary to
facilitate this process.
Public Health Risks: We may disclose your protected health information, if necessary, in order to
prevent or control disease, report adverse events from medications or products, prevent injury, disability,
or death. This information may be disclosed to healthcare systems, government agencies, or public
health authorities. We may have to disclose your protected health information to the Food and Drug
Administration to report adverse events, defects, problems, enable recalls, etc. if required by FDA
Health Oversight Activities: We may disclose protected health information to health oversight agencies
for audits, investigations, inspections, or licensing purposes. These disclosures might be necessary for
state and federal agencies to monitor healthcare systems and compliance with civil law.
Required by Law: We will disclose protected health information about you when required to do so by
federal, state, and/or local law.
Workman’s compensation: We may disclose your protected health information to workman’s comp or
Lawsuits: We may disclose your protected health information in response to court action, administrative
action, or a subpoena.
Law Enforcement: We may release protected health information to a law enforcement official in
response to a court order, subpoena, warrant, subject to all applicable legal requirements.
YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION
Access to medical records: You have the right to access and receive copies of your protected health
information that we use to make decisions about your care. You must submit a written request to obtain
your protected health information to our office. We reserve the right to charge you a fee for the time it
takes to obtain and copy the protected health information and provide it to you.
Amendment: If you believe that protected health information we have about you is incorrect or
incomplete, you may ask us to amend the information. You will need to submit a written request on why
you feel the health information should be amended. We may deny your request to amend if you did not
send a written request or give a reason on why it should be amended. If we deny your request, we will
provide you a written explanation. We may deny your request if we believe the protected health
information is accurate and complete.
Accounting of Disclosures: You have the right to receive a list of instances in which we disclosed your
personal health information unless the disclosure was used for treatment, payment, healthcare
operations, was pursuant to a valid authorization and as otherwise provided in applicable federal and
state laws and regulations. You must submit a written request to obtain this “accounting of disclosures”
to our office. After your request has been approved, we will provide you the dates of the disclosure, the
name of the individual or entity we disclosed the information to, a description of the information that
was disclosed, the reason why it was disclosed, and any additional pertinent information. This
information may not be longer than (STATUTE OF LIMITATIONS) years ago prior to the date the
accounting is requested. We reserve the right to charge a reasonable fee for this process.
Restriction Requests: You have the right to request a restriction or limitation on the protected health
information we use or disclose about you for treatment, payment, or healthcare operations. We shall
accommodate your request except where the disclosure is required by law. We require this to be a
written request submitted to our office.
Confidential Communication: You have the right to request that we communicate with you about
healthcare matters in a certain way and at a certain location. We must accommodate your request if it is
reasonable and allows us to continue to collect payments and bill you.
A paper copy of this notice: You may obtain a paper copy of this notice from us upon request. You
have this right even if you have agreed to receive the Notice electronically. You may request a copy of
our notice at any time. You may contact us @ 602.699.4536 or email @ firstname.lastname@example.org to
request a copy of these privacy policies.
Changes to this Notice: We are required to abide by the terms of the Notice of Privacy Practices
currently in effect. We reserve the right to change the terms of these policies at any time. If we change
our privacy policies, we will notify you of these changes immediately. This current policy is in effect
unless stated otherwise. If the policy is changed, it will apply to all your current and past health
information. We will post a copy of the current notice in our office or on our website. You may request a
copy of a revised Notice of Privacy Practices from our office.
Complaints: You have recourse if you feel that your privacy rights have been violated. You have the
right to file a written complaint with our office, or with the Department of Health & Human Services,
Office of Civil Rights, about violations of the provisions of this notice or the policies procedures of our
office. We will not retaliate against you for filing a complaint.
For more information about HIPAA or to file a complaint:
The U.S. Department of Health & Human Services, Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201
ACKNOWLEDGEMENT RECEIPT OF PRIVACY PRACTICES
By signing below, I acknowledge that I have read and understood the Notice of Privacy Practices of
New Roads Health, which explains its legal duties and privacy practices with respect to my protected
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