HIPAA Notice of Privacy Practices

Authorization Form to Release Information (PHI):  


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. This information is provided to you pursuant to the Health Insurance Portability and Accessibility Act of 1996 ("HIPAA"). It is designed to tell you how we may, under federal law, use or disclose your Health Information.

We May Use or Disclose Your Health Information for Purposes of Treatment, Payment or Healthcare Operations With Consent. Here is One Example of Each:

  • The health care professionals - including doctors, nurses and technicians - in our office may access your information for purposes of providing you care.

  • Our billing department may access your information - and send relevant parts - to your insurance company to allow us to be paid for the service we render to you.

  • We may access or send your information to our attorneys or accountants in the event we need the information in order to address one of our own business functions.


We May Use or Disclose Your Health Information Under the Following Circumstances Without Obtaining Your Prior Consent or Authorization:

  • For Treatment, Payment or Health care Operations. See above.

  • To Provide it to You.

  • To Notify and/or Communicate with your Family: Unless you tell us you object, we may use or disclose your Health Information in order to notify your family or assist in notifying your family, your personal representative or another person responsible for your care about your location, your general condition or in the event of your death.  If you are unable or unavailable to agree or object, our health professionals will use their best judgement in communicating with your family and others.

  • As Required by Law.

  • For Public Health Purposes: We may use or disclose your Health Information to provide information to state or federal publice health authorities, as required by law to prevent or control disease, injury or disability; to report child abuse or neglect; to report domestic violence; to report to the Food and Drug Administration problems with products and reactions to medications; and to report disease or infection exposure.

  • For Health Oversight Activities: We may use or disclose your Health Information to health agencies during the course of audits, investigations, inspections, licensure, and other proceedings.

  • In Response to Subpoenas or for Judicial and Administrative Proceedings: We may use or disclose your Health Information in the course of any administrative or judicial proceeding.  However, in general we will attempt to ensure that you have been made aware of the use or disclosure of your Health Information prior to providing it to another person.

  • To Law Enforcement Personnel: We may use or disclose your Health Information to a law enforcement official to identify or locate a suspect, fugitive, material witness, or missing person; to comply with a court order or subpoena, and other law enforcement purposes.

  • To Coroners or Funeral Directors: We may use or disclose your Health Information for purposes of communicating with coroners, medical examiners, and funeral directors.

  • For Public Safety: We may use or disclose your Health Information in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.

  • To Aid Specialized Governmental Functions: If necessary, we may use or disclose your Health Information for military or national security purposes.

  • For Worker's Compensation: We may use or disclose your Health Information as necessary to comply with worker's compensation laws.

For All Other Circumstances, We May Only Use or Disclose Your Health Information After You Have Signed an Authorization. If you authorize us to use your Health Information for another purpose, you may revoke your authorization in writing at any time.

We May Also Use or Disclose Your Health Information for the Following Purposes:

  • Appointment Reminders, Schedule Calendars, Newsletters, and Birthday Cards: We may use your Health Information in order to contact you to provide appointment reminders, schedule calendars, newsletters, birthday cards or to give information about other treatments or health-related benefits and services that may be of interest to you.

  • Surveys to Measure Patient Satisfaction: We may contact you to participate in surveys to check on satisfaction with services.

  • Fund Raising: We may contact you to participate in our fund-raising activities.

  • Change of Ownership: In the event that our agency is sold or merged with another organization, your Health Information / record will become the property of the new owner.

Your Rights:

  • You have the right to request restrictions on the uses and disclosures of your Health Information.  We are not required to comply with your request.

  • You have the right to receive your Health Information through confidential means, through a reasonable alternative means, or at an alternative location.

  • You have a right to inspect and copy your Health Information at a reasonable cost-based fee to cover copying, postage, and/or preparation of summary.

  • You have the right to request that we amend your Health Information that is incorrect or incomplete.  We are not required to change your information and will provide you with information about our denial and how you can disagree with our denial.

  • You have a right to receive an accounting of disclosures of your Health Information made by us, except that we do not have to account for the following disclosures: treatment, payment, health care operations, information provided to you, notification and communication with family, certain government functions, appointment reminders, and fund raising described earlier in this Notice of Privacy Practices.

  • You have a right to a paper copy of this Notice of Privacy Practices.  If you would like to have a more detailed explanation of these rights or if you would like to exercise one or more of these rights, contact our Privacy Officer.

Our Duties:

  • We are required by law to maintain the privacy of your Health Information and to provide you with a copy of this Notice.

  • We are also required by law to abide by this Notice.

  • We reserve the right to amend this Notice at any time in the future and to make the new notice provisions applicable to all your Health Information - even if it was created prior to the change in the Notice.  If such an amendment is made, we will immediately display the revised Notice at our office, on our website and provide you with a copy of the amended Notice.  We will also provide you with a copy, at any time, upon request.


Complaints to the Government:

  • You may make complaints to the Secretary of the Department of Health and Human Services if you believe your rights have been violated.  You may contact DHHS at (866) 627-7748.

  • We promise not to retaliate against you for any complaint you make to the government about our privacy practices.

Contact Information:

  • You may contact us about our privacy practices by calling the office at 954-593-2059.