Notice of privacy practices
Effective date: 12/11/2019
Notice Of Privacy Practices
As required by the privacy regulations created as a result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
This notice describes how health information about you (as a
patient of this practice) may be used and disclosed and how you
can get access to your individually identifiable health information.
Please review this notice carefully.
A. Our commitment to your privacy:
Our practice is dedicated to maintaining the privacy of your individually identifiable health information (also called protected health information, or PHI). In conducting our business, we will create records regarding you and the treatment and services we provide to you. We are required by law to maintain the confidentiality of health information that
identifies you. We also are required by law to provide you with this notice of our legal duties and the privacy practices that we maintain in our practice concerning your PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.
We realize that these laws are complicated, but we must provide you with the following important information:
• How we may use and disclose your PHI
• Your privacy rights in your PHI
• Our obligations concerning the use and disclosure of your PHI.
The terms of this notice apply to all records containing your PHI that are created or retained by our practice. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all of your
records that our practice has created or maintained in the past, and for any of your records that we may create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible location at all times, and you may request a copy of our most current Notice at any time.
C. We may use and disclose your PHI in the following ways:
Copyright © 2019 by the American Academy of Family Physicians. All rights reserved.
The following categories describe the different ways in which we may use and disclose your PHI.
1. Recommendations: Our staff will use your PHI to review and process your medical recommendations. If there are any tests performed, this will be documented in your PHIand used to make recommendation decisions.
2. Payment. Our practice may use and disclose your PHI in order to bill and collect payment for the services you may receive from us. We may use your PHI to bill you directly for services.
3. Health care operations. Our practice may use and disclose your PHI to operate our business. As examples of the ways in which we may use and disclose your information for our operations, our practice may use your PHI to evaluate the quality of care you
received from us, or to conduct cost-management and business planning activities for our practice.
4. Appointment reminders. Our practice may use and disclose your PHI to contact you and remind you of an appointment.
5. Treatment options. Our practice may use and disclose your PHI to inform you of potential treatment options or alternatives.
6. Health-related benefits and services. Our practice may use and disclose your PHI to inform you of health-related benefits or services that may be of interest to you.
7. Disclosures required by law. Our practice will use and disclose your PHI when we are required to do so by federal, state or local law.
D. Use and disclosure of your PHI in certain special circumstances:
You have the following rights regarding the PHI that we maintain about you: 1. Confidential communications. You have the right to request that our practice communicates with you about your health and related issues in a particular manner or at a
certain location. In order to request a specific type of confidential communication, you must make a written request firstname.lastname@example.org specifying the requested method of contact, or the location where you wish to be contacted. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.
2. Requesting restrictions. You have the right to request a restriction in our use or disclosure of your PHI for treatment, payment or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI to only certain individuals involved in your care or the payment for your care, such as family members and friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies or when the information is necessary to treat you. In order to request a restriction in our use or disclosure of your PHI, you must make your request in writing email@example.com. Your request must describe in a clear and concise fashion:
• The information you wish restricted,
• Whether you are requesting to limit our practice’s use, disclosure or both,
• To whom you want the limits to apply.
3. Inspection and copies. You have the right to inspect and obtain a copy of the PHI that may be used to make decisions about you, including patient medical records and billing
records, but not including psychotherapy notes. You must submit your request in writing to firstname.lastname@example.org in order to inspect and/or obtain a copy of your PHI. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our
practice may deny your request to inspect and/or copy in certain limited circumstances; however, you may request a review of our denial. Another licensed health care professional chosen by us will conduct reviews.
4. Amendment. You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing and submitted email@example.com.
You must provide us with a reason that supports your request for amendment. Our practice will deny your request if you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you ask us to amend information that is in our opinion: (a) accurate
Copyright © 2018 by the American Academy of Family Physicians. All rights reserved.
and complete; (b) not part of the PHI kept by or for the practice; (c) not part of the PHI which you would be permitted to inspect and copy; or (d) not created by our practice,
unless the individual or entity that created the information is not available to amend the
5. Accounting of disclosures. All of our patients have the right to request an “accounting
of disclosures.” An “accounting of disclosures” is a list of certain non-routine disclosures
our practice has made of your PHI for purposes not related to treatment, payment or operations. Use of your PHI as part of the routine patient care in our practice is not required to be documented – for example, the doctor sharing information with the nurse;
or the billing department using your information to complete a credit card order. In order to obtain an accounting of disclosures, you must submit your request in writing to
All requests for an “accounting of disclosures” must state a time period, which may not be longer than six (6) years from the date of disclosure and may not include dates before 15 April 14, 2003.
6. Right to a paper copy of this notice. You are entitled to receive a paper copy of our notice of privacy practices. You may ask us to give you a copy of this notice at any time.
7. Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our practice, contact [insert name or title and telephone number of the contact person or office responsible for handling complaints. All complaints must be submitted in writing. You will not be penalized for
filing a complaint.
8. Right to provide authorization for other uses and disclosures. Our practice will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by applicable law. Any authorization you provide to us regarding the
use and disclosure of your PHI may be revoked at any time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described
in the authorization. Please note: we are required to retain records of your care.
From time to time, we may need to send an announcement to your provided opt-in email account. No further information will be shared; your email may be used for marketing and information and you may opt-out at any time.