HIPAA Notice of Privacy Practices

This notice describes how medical information about you may be used anddisclosed and how you can get access to this information. Please reviewit carefully.

If you have any questions about this Notice, please contact our Privacy Contact who is: Connie Veronis.

ThisNotice of Privacy Practices describes how we may use and disclose yourprotected health information to carry out treatment, payment or healthcare operations and for other purposes that are permitted or requiredby law. It also describes your rights to access and control your“protected health information.” “Protected health information” isinformation about you, including demographic information, that mayidentify you and that relates to your past, present or future physicalor mental health or condition and related health care services.

Weare required to abide by the terms of this Notice of Privacy Practices.We may change the terms of our notice, at any time. The new notice willbe effective for all protected health information that we maintain atthat time. Upon your request, we will provide you with any revisedNotice of Privacy Practices by fax or mail, calling the office andrequesting that a revised copy be sent to you in the mail, or askingfor one at the time of your next appointment.

1. Use and Disclosures of Protected Health Information

Uses and Disclosures of Protected Health Information Based Upon Your Written Consent

Youwill be asked by this agency to sign a consent form. Once you haveconsented to use and disclosure of your protected health informationfor treatment, payment and health care operations by signing theconsent form, the agency will use and disclose your protected healthinformation as described in this Section 1. Your protected healthinformation may be used and disclosed by the agency, our office staffand others outside our office, that are involved in your care andtreatment for the purpose of providing health care services to you.Your protected health information may also be used and disclosed to payyour health care bills and to support the operation of the agency.

Followingare examples of the types of uses and disclosures of your protectedhealth information that the agency is permitted to make once you havesigned our consent form. These examples are not meant to be exhaustive,but to describe the types of uses and disclosures that may be made byour office once you have provided consent.

Treatment. We willuse and disclose your protected health information to provide,coordinate, or manage your health care and any related services. Thisincludes the coordination or management of your health care with athird party that has already obtained your permission to have access toyour protected health information. For example, we would disclose yourprotected health information, as necessary, to a physician’s officethat provides care to you. We will also disclose protected healthinformation to other physicians who may be treating you when we havethe necessary permission from you to disclose your protected healthinformation. For example, your protected health information may beprovided to a physician to whom you have been referred, to ensure thatthe physician has the necessary information to diagnose or treat you.

Inaddition, we may disclose your protected health information from timeto time to another physician or health care provider (e.g., aspecialist or laboratory) who, at the request of the agency, becomesinvolved in your care by providing assistance with your health carediagnosis or treatment.

Payment. Your protected healthinformation will be used, as needed, to obtain payment for your healthcare services. This may include certain activities that your healthinsurance plan may undertake before it approves or pays for the healthcare services we recommend for you, such as: making a determination ofeligibility or coverage for insurance benefits; reviewing servicesprovided to you for medical necessity, and undertaking utilizationreview activities. For example, obtaining approval for an agencyservice may require that our relevant protected health information bedisclosed to the payer source to obtain approval for the servicesprescribed.

Healthcare Operations. We may use or disclose, asneeded, your protected health information in order to support thebusiness activities of the agency. These activities include, but arenot limited to, quality assessment activities, employee reviewactivities, training of new employees, in-services, and/or conductingother agency activities. For example, we may disclose your protectedhealth information to student nurses seeing patients in our agency. Inaddition, we may use a sign-in sheet at the registration desk where youwill be asked to sign your name. We may also call you by name in thewaiting room when your physician is ready to see you. We may use ordisclose your protected health information, as necessary, to contactyou to remind you of your next appointment.

We will share ordisclose your protected health information with third party “businessassociates” that perform various activities (e.g., billing) for theagency. Whenever an arrangement between our office and a businessassociate involves the use or disclosure of your protected healthinformation, we will have a written contract that contains terms thatwill protect the privacy of your protected health information.

Wemay use or disclose your protected health information, as necessary, toprovide you with information about treatment alternatives or otherhealth-related benefits and services that may be of interest to you. Wemay also use and disclose your protected health information for othermarketing activities. For example, your name and address may be used tosend you a newsletter about our agency and the services we offer. Wemay also send you information about products or services that webelieve may be beneficial to you. You may contact our Privacy Contactto request that these materials not be sent to you.

We may useor disclose your demographic information and the dates that youreceived treatment from the agency, as necessary, in order to contactyou for activities related to the agency. If you do not want to receivethese materials, please contact our Privacy Contact and request thatthese materials not be sent to you.

Uses and Disclosures of Protected Health Information Based Upon Your Written Authorization

Otheruses and disclosures of your protected health information will be madeonly with your written authorization, unless otherwise permitted orrequired by law as described below. You may revoke this authorization,at any time in writing, except to the extent that the agency has takenan action in reliance on the use or disclosure indicated in theauthorization.

Other Permitted and Required Uses and Disclosures That May Be Made With Your Consent, Authorization or Opportunity to Object

Wemay use and disclose your protected health information in the followinginsurances: You may have the opportunity to agree or object to the useor disclosure of all or part of your protected health information. Ifyou are not present or able to object to the use or disclosure of theprotected health information, then the agency may, using professionaljudgment, determine whether the disclosure is in your best interest. Inthis case, only the protected health information that is relevant toyour health care will be disclosed.

Others Involved in YourHealthcare: Unless you object, we may disclose to a member of yourfamily, a relative, a close friend or any other person you identify,your protected health information that directly relates to thatperson’s involvement in your health care. If you are unable to agree orobject to such a disclosure, we may disclose such information asnecessary if we determine that it is in your best interest based on ourprofessional judgment, with the exclusion of FPL information which weare prohibited by Federal Law to release. We may use or discloseprotected health information to notify or assist in notifying a familymember, a personal representative or any other person that isresponsible for your care of your location, general condition or death.Finally, we may use or disclose your protected health information to anauthorized public or private entity to assist in disaster reliefefforts and to coordinate uses and disclosures to family or otherindividuals involved in our health care.

Emergencies: We may use or disclose your protected health information in an emergency treatment situation.

CommunicationBarriers: We may use and disclose your protected health information ifthe agency attempts to obtain consent from you but is unable to do sodue to substantial communication barriers and the agency determines,using professional judgment, that you intend to consent to use ordisclose under the circumstances.
Other Permitted and Required Uses and Disclosures That May Be Made Without Your Consent, Authorization or Opportunity to Object

Wemay use or disclose your protected health information in the followingsituations without your s\consent or authorization. These situationsinclude:

Required By Law: We may use or disclose your protectedhealth information to the extent that the use or disclosure is requiredby law. The use or disclosure will be made incompliance with the lawand will be limited to the relevant requirements of the law. You willbe notified, as required y law, of any such uses or disclosures.

PublicHealth: We may disclose your protected health information for publichealth activities and purposes to a public health authority that ispermitted by law to collect or receive the information. The disclosurewill be made for the purposes of controlling disease, injury ordisability. We may also disclose your protected health information, ifdirected by the public health authority, to a foreign government agencythat is collaborating with the public health authority.

CommunicableDiseases: We may disclose protected health information, if authorizedby law, to a person who may have been exposed to a communicable diseaseor may otherwise be at risk of contracting or spreading the disease orcondition.

Health Oversight: We may disclose protected healthinformation to a health oversight agency for activities authorized bylaw, such as audits, investigations or inspections. Oversight agenciesseeking this information include government agencies that oversee thehealth care system, government benefit programs, other governmentregulatory programs and civil rights laws.

Abuse or Neglect: Wemay disclose your protected health information to a public healthauthority that is authorized by law to receive reports of child abuseor neglect. In addition, we may disclose your protected healthinformation if we believe that you have been a victim of abuse, neglector domestic violence to the governmental entity or agency authorized toreceive such information. In this case, the disclosure will be madeconsistent with the requirements of applicable federal and state laws.

Foodand Drug Administration: We may disclose your protected healthinformation to a person or company required by the Food and DrugAdministration to report adverse events, product defects or problems,biologic product deviations, track products; to enable product recalls;to make repairs or replacements, or to conduct post marketingsurveillance, as required.

Legal Proceedings: We may discloseprotected health information in the course of any judicial oradministrative proceeding, in response to an order of a court oradministrative tribunal (to the extent such disclosure is expresslyauthorized); in certain conditions in response to a subpoena, discoveryrequest or other lawful process.

Law Enforcement: We may alsodisclose protected health information, so long as applicable legalrequirements are met, for law enforcement purposes. These lawenforcement purposes include (1) legal processes as otherwise requiredby law, (2) limited information requests for identification andlocation purposes, (3) pertaining to victims of a crime, (4) suspicionthat death has occurred as a result of criminal conduct, (5) in theevent that a crime occurs on the premises of the agency, and (6)medical emergency (not on the agencies premises) and it is likely thata crime has occurred.

Coroners, Funeral Directors, andOrgan Donation: We may disclose protected health information to acoroner or medical examiner for identification purposes, determiningcause of death or for the coroner or medical examiner to perform otherduties authorized by law. We may also disclose protected healthinformation to a funeral director, as authorized by law, in order topermit the funeral directory to carry out their duties. We may disclosesuch information in reasonable anticipation of death. Protected healthinformation may be used and disclosed for cadaveric organ, eye ortissue donation purposes.

Research: We may disclose yourprotected health information to researchers when their research hasbeen approved by an institutional review board that has reviewed theresearch proposal and established protocols to ensure the privacy ofyour protected health information.

Criminal Activity: Consistentwith applicable federal and state laws, we may disclose your protectedhealth information, if we believe that the use or disclosure isnecessary to prevent or lessen a serious and imminent threat to thehealth or safety of a person or the public. We may also discloseprotected health information if it is necessary for law enforcementauthorities to identify or apprehend an individual.

MilitaryActivity and National Security: When the appropriate conditions apply,we may use or disclose protected health information of individuals whoare Armed Forces personnel, (1) for activities deemed necessary byappropriate military command authorities; (2) for the purpose of adetermination by the Department of Veterans Affairs of your eligibilityfor benefits, or (3) to foreign military authority if you are a memberof that foreign military services. We may also disclose your protectedhealth information to authorized federal officials for conductingnational security and intelligence activities, including for theprovision of protective services to the President or others legallyauthorized.

Workers’ Compensation: Your protected healthinformation may be disclosed by us as authorized to comply withworkers’ compensation laws and other similar legally-establishedprograms.

Inmates: We may use or disclose your protected healthinformation if you are an inmate of a correctional facility and theagency created or received your protected health information in thecourse of providing care to you.

Required Uses and Disclosures:Under the law, we must make disclosures to you and when required by theSecretary of the Department of Health and Human Services to investigateor determine our compliance with the requirements of Section 154.500et. Seq.
2. Your Rights

Following is a statementof your rights with respect to your protected health information and abrief description of how you may exercise these rights.

You havethe right to inspect and copy your protected health information. Thismeans you may inspect and obtain a copy of protected health informationabout you that is contained in a designated record set for as long aswe maintain the protected health information. A “designated record set”contains medical and billing records and any other records that theagency uses for making decisions about you.

Under federal law,however, you may not inspect or copy the following records;psychotherapy notes; information compiled in reasonable anticipationof, or use in, a civil, criminal or administrative action or proceedingand protected health information that is subject to law that prohibitsaccess to protected health information. Depending on the circumstances,a decision to deny access may be reviewable. In some circumstances, youmay have a right to have this decision reviewed. Please contact ourPrivacy Contact if you have questions about access to your medicalrecord.

You have the right to request a restriction of yourprotected health information. This means you may ask not to use ordisclose any part of your protected health information for the purposesof treatment, payment or healthcare operations. You may also requestthat any part of your protected health information not be disclosed tofamily members or friends who may be involved in your care or fornotification purposes as described in this Notice of Privacy Practices.Your request must state the specific restriction requested and to whomyou want the restriction to apply.

The agency is not required toagree to a restriction that you may request. If the agency believes itis in your best interest to permit use and disclosure of your protectedhealth information, your protected health information will not berestricted. If the agency does agree to the requested restriction, wemay not use or disclose your protected health information in violationof that restriction unless it is needed to provide emergency treatment.With this in mind, please discuss any restriction you wish to requestwith the agency. You may request a restriction by placing your requestin writing and presenting it to our Privacy Contact.

You havethe right to request to receive confidential communications from us byalternative means or at an alternative location. We will accommodatereasonable requests. We may also condition this accommodation by askingyou for information as to how payment will be handled or specificationof an alternative address or other method of contact. We will notrequest an explanation from you as to the basis for the request. Pleasemake this request in writing to our Privacy Contact.

You mayhave the right to have the agency amend tour protected healthinformation. This means you may request an amendment of protectedhealth information about you in a designated record set for as long aswe maintain this information. In certain cases, we may deny yourrequest for an amendment. If we deny your request for an amendment, youhave the right to file a statement of disagreement with us and we mayprepare a rebuttal to your statement and will provide you with a copyof any such rebuttal. Please contact our Privacy Contact to determineif you have questions about amending your medical record.

Youhave the right to receive an accounting of certain disclosures we havemade, if any, of your protected health information. This right appliesto disclosures for purposes other than treatment, payment or healthcareoperations as described in this Notice of Privacy Practices. Itexcludes disclosures we may have made to you, to family members orfriends involved in your care, or for notification purposes. You havethe right to receive specific information regarding these disclosuresthat occurred after April 13, 2003. You may request a shortertimeframe. The right to receive this information is subject to certainexceptions, restrictions and limitations.

You have the right toobtain a paper copy of this notice from us. Upon request, even if youhave agreed to accept this notice electronically.

3. Complaints:

Youmay complain to us or to the Secretary of Health and Human Services ifyou believe your privacy rights have been violated by us. You may filea complaint with us by notifying our Privacy Contact of your complaint.We will not retaliate against you for filing a complaint.

You may contact our Privacy Contact, Connie Veronis, at (304) 845-7840 for further information about the complaint process.

This notice was published and becomes effective on April 14, 2003.