- apc.staff110@gmail.com
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 (PHI) and to provide you with notice of our legal duties and privacy practices. We are committed to protecting your PHI.
We may use and disclose your PHI without your written authorization for treatment, payment, and healthcare operations (TPO).
We may use and disclose your PHI to provide, coordinate, or manage your health care and related services. This includes consultation with, and referrals to, other health care providers.
Example: We may share your health information with your psychiatrist or primary care physician to coordinate your ongoing treatment.
We may use and disclose your PHI to obtain payment for the health care services we provide to you.
Example: We may disclose your PHI to your health insurance plan to confirm coverage, eligibility, and medical necessity prior to service, and to submit claims for reimbursement.
We may use and disclose your PHI for our own operations, which are necessary to manage the practice and ensure all patients receive quality care.
Example: We may use PHI to review our treatment procedures and assess the performance of our staff in caring for you.
We will not use or disclose your PHI for certain purposes without your specific written authorization. Once you authorize the release of your PHI, you may revoke that authorization in writing at any time, except to the extent that we have already taken action based on your authorization.
Authorization is generally required for:
Marketing: Most uses and disclosures of PHI for marketing purposes.
Sale of PHI: Disclosures that constitute a sale of PHI.
Psychotherapy Notes: Most uses and disclosures of psychotherapy notes (if applicable to the practice).
Other Purposes: Any other uses or disclosures of PHI not described in this Notice.
We may use or disclose your PHI without your authorization for the following reasons, subject to all applicable legal requirements and limitations:
Public Health Activities: To prevent or control disease, injury, or disability, or to report reactions to medications.
Victims of Abuse, Neglect, or Domestic Violence: To governmental authorities as required by law.
Health Oversight Activities: Disclosures to agencies authorized to conduct audits, investigations, inspections, and licensure reviews (e.g., HHS).
Judicial and Administrative Proceedings: In response to a court order, subpoena, discovery request, or other lawful process.
Law Enforcement Purposes: For purposes of identifying or locating a suspect, fugitive, material witness, or missing person.
Workers’ Compensation: As authorized by and to the extent necessary to comply with laws relating to workers’ compensation or other similar programs.
Health and Safety: To prevent a serious threat to your health and safety or the health and safety of others.
You have the following rights concerning your PHI, and we will honor them according to the law. To exercise any of these rights, you must submit a written request to the Privacy Officer listed in Section 6.
Your Right | Description of the Right |
|---|---|
Right to Inspect and Copy | You have the right to inspect and obtain a copy of PHI maintained by us (e.g., medical and billing records), subject to limited exceptions. |
Right to Amend | If you believe that the PHI we have about you is incorrect or incomplete, you may request that we amend the information. We may deny your request if we determine the record is accurate and complete, but we will provide you with a written explanation of our decision. |
Right to an Accounting of Disclosures | You have the right to request a list (accounting) of certain disclosures of your PHI made by us for purposes other than TPO. |
Right to Request Restrictions | You have the right to request a restriction or limitation on the PHI we use or disclose about you for treatment, payment, or health care operations. We are not required to agree to your request, except in the specific case where you pay for a service in full out-of-pocket and request that we not disclose PHI related solely to that service to your health plan. |
Right to Confidential Communications | You have the right to request that we communicate with you about health matters in a certain way or at a certain location (e.g., mail to your work address only). We will accommodate reasonable requests. |
Right to a Paper Copy of this Notice | You have the right to a paper copy of this Notice, even if you have agreed to receive this Notice electronically. |
Right to be Notified of a Breach | You have the right to be notified if your unsecured PHI has been compromised in a breach. |
We are required by law to:
Maintain the privacy and security of your PHI.
Provide you with this Notice of our legal duties and privacy practices.
Notify you following a breach of your unsecured PHI.
Abide by the terms of the Notice currently in effect. We reserve the right to change the terms of our Notice and make the new provisions effective for all PHI we maintain. If we make material changes, we will post the revised Notice on our website and in our office.
If you believe your privacy rights have been violated, you may file a complaint with our practice or with the Secretary of the U.S. Department of Health and Human Services (HHS).
To file a complaint with us: You will not be penalized or retaliated against for filing a complaint.
Privacy Officer: Office Staff
Telephone: [Practice Phone Number – Required by HIPAA. Must be provided by client.]
Email: apc.staff110@gmail.com
To file a complaint with the Secretary of HHS:
Office for Civil Rights (OCR)
U.S. Department of Health and Human Services
200 Independence Avenue, S.W.
Washington, D.C. 20201
