Protecting Your Confidential Health Information is Important to Us

Judicial and Administrative Proceedings

We may disclose your health infomation in an administrative or judicial proceeding in response to'a subpoena or a request to produce documents. We will disclose your health information in these circumnances only if the requesting party first provides written documentation that the privacy of your health information will be protected.

Incidental Uses and Disclosures

We may use or disclose your health infomation in a manner which is incidental tothe uses and disclosures deseribed in this Notice.

Health Oversight Activities

We may disclose your health information to a government agency responsible for overseeing the health care system or health-related govemment benefit program.

To Avert A Serious Threat To Heath or Safety.

We may use or disclose your health information to reduce a risk of serious and imminent harm to another person or to the public.

To The U.S. Department of Health and Human Services (HHS)

We may disclose your health informa’tion to HHS. the government agency responsible for overseeing compliance with federal privacy law and regulations regulating the privacy and security of health information.

For Research

We may use or disclose your health information for research. subject to conditions. “Research“ means systemic investigation designed to contribute to generalized knowledge

In Connection With Your Death Or Organ Donation

We may disclose your health information to a coroner for identification purposes. to a funeral director for funeral purposes. or to an organ procurement organization to facilitate transplantation of one of your organs. If applicable State law does not permit the disclosure described above. we will comply with the stricrer State law.

Authorization to Use or Disclose Health Information

Other than is stated above or where Federal, State or Local law requires us. we will not disclose your health information other than with your written authorization. You may revoke that authorization in writing at any time.


You have the following rights related to your health Information.


You have the right to request restrictions on the use or disclosure of your health information for treatment. payment. or health care operations in addition to the

Patient Ackndwledgment

Thank you very much for taking time to review how we are carefully using your health information. If you have any questions we want to hear from you. If not we would appreciate very much your acknowledging your receipt of our policy by signing and returning this card. We look forward to seeing you again soon!.

restrictions imposed by federal law. Our office not required to'agree to your request, but we will endeavor to honor reasonable requests. We generally are not required to agree to a requested restriction Our office will horror your request that we not disclose your health information to a health plan for payment or healthcare operation purposes if the health information relates solely to a health care item or service for which you have-paid us out-of-pocket in full.

Confidential Communications

You have the right to request that we communicate with you by alternative means or-at an alternative location, You may for Example, request that we
communicate your health information only privately with novothet family , members present or through mailed communications that are sealed We will honor your reasonable requests for Confidential communications.

Inspect and Copy Your Health Information

You have the right to read review. and- copy your health information. including your complete chart x-rays and billing records. If you would like a copy of your health information‘ please let us knowt'We may need to charge you a reasonable. cost-based fee to duplicate and assemble your copy. lf there
will be a charge. we will first contact you to determine whether you wish to modify or wimdraw your request.

Amend Your Health lnformation

You have the right to ask us to update or modify your records if you believe your health information records are incorrect or incomplete. We will be happy to accommodate you as long as our office mai‘ritairis this information. In order to standardize our process. please provide ‘us with your request in writing and describe the information to be changed and your reason for‘the change.

Your request may be denied if the health information recordin question was nor created by our office. is not part of our records or if there cords-containing your health information are deterrnined-to be accurate and complete. lf we deny your request we will provide you with a written explanation of the denial.

Accounting of Disclosures of Your Health loformation You have the right to ask us for a description of how and where your health information was disclosed Our documentation procedures will enable us to provide information on health information disclosures that we are required to disclose to you. Please let us know in writing the time period for which you are interested. Thank you for limiting your request to no more than six years at a
time. We will provide the first accounting during any lZ-momh period without charge. We may charge a reasonable cost-based fee for each additional
accounting during the same 12-month period. If there will be a charge. the Privacy Official will first contact you to determine whether you wish to modify or withdraw your request.

Request a Paper Copy of this Notice

You have the light to obtain a copy of this Notice of Privacy Practices directly from our office at any time, Stop by or give us a call and we will mail or email a copy to you.

We are required by law to maintain the privacy of your health information and to provide to you or your personal representative with this Notice of our Privacy Practices. We are required to practice the policies and procedures described in this notice bur we do reserve the right to change the terms of our Notice, If we change our privacy practices we will be sure all of our patients receive a copy of the revised Notice, You have the right to express complaints to us or to the Secretary of Health and Human Services if you believe your privacy rights have been compromised We encourage you to express any concerns you may have regarding the privacy of your information. We will not retaliate against you for submitting a complaint. Please let us know of your concerns or complaints in writing by submitting your complaint to our Privacy Officer.
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