notice details how your medical information may be used and disclosed
and how you may access this information. Please review the following
The Health Insurance Portability & Accountability Act of
1996 (HIPAA), is a federal program which requires that all
medical records and all other pertinent individualized health
information used or disclosed by any healthcare facility/provider
in any form, whether by paper, orally, or electronically, be
kept confidential at all times. This ACT gives patients new
rights allowing patients to control how their health information
is kept and used. Misuse of this personal health information
(PHI) will result in penalties from HIPAA.
As required by HIPAA, this statement will explain how we are
required to maintain privacy of all health information and
how we can use and disclose this information.
Your medical record/health information may
only be used and/or disclosed for the following reasons:
TREATMENT, PAYMENT, AND HEALTHCARE OPERATIONS.
We may also re-identify all health information by removing
any references that have identifiable individual information.
Any other type of disclosures will only be allowed after your written consent
**You have the following rights to your protection
of health information. You may at any time exercise these rights
by filing a written request to our office:
right to request restrictions of certain uses/disclosures
of your health information.
• The right to
review and/or obtain a copy of your health information.
right to amend your health information.
to receive an account of all disclosures of your
•The right to obtain a copy of
this notice at any time.
We are required by law to maintain the privacy
of your health information, and to provide you with notice of
our legal privacy practices in regards to your private healthcare
This notice shall serve effective as of the DAY OF APRIL, 2003. We are required
to abide by the terms of this Privacy Notice. We maintain the right to change
the terms of this Privacy Notice at any time. You have the right to request
a current copy of this Privacy Notice at any time.
You have rights protecting your privacy; if you feel that these rights have
been violated, you have the right to file a written complaint for any violations
of this Privacy Notice.
If you need further information on HIPAA, or to file a complaint, please contact
our office or:
The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington D.C., 20201
Toll Free: 1-877-696-6775