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.
Treatment. Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures and will be available in your medical record to all health processionals who may provide treatment or who may be consulted by staff members.
Payment. Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated.
Health care operations. Your health information may be used as necessary to support the day-to-day activities and management of this medical practice. For example, information on the services you receive may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.
Law enforcement. Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.
Public health reporting. Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department.
Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above required your specific written authorization. If you change your mind after authorizing a use of disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision.
Appointment reminders. Your health information will be used by our staff to send you appointment reminders.
Information about treatments. Your health information may be used to send you information on the treatment and management of your medical condition that you may find to be of interest. We may also send your information describing other health-related goods and service that we believe may interest you.
You have certain rights under the federal privacy standards. These Include:
We are required by law to maintain the privacy of your protected health information and to provide you with the notice of privacy practices.
We also are required to abide by the privacy policies and practices that are outlined in the notice.
As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Whatever reason for these revisions, we will provide you with a revised notice on your next office visit. The revised policies and practices will be applied to all protected health information that we maintain.
As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting the practice administrator.
If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern.
You will not be penalized or otherwise retaliated against for filling a complaint.
This notice is effective on or after April 14th, 2003
Use and Disclosure of your Protected Health Information
Your protected health information will be used by this medical practice or disclosed to others for the purpose of treatment, obtaining payment, or supporting the day-to-day health care operations of the practice.
You should review the Notice of Privacy Practices for a more complete description of how your protected health information may be used and disclosed. You may review the notice prior to signing the consent.
Requesting a Restriction on the Use or Disclosure of Your Information
You may request a restriction on the use of disclosure of your protected health information.
This medical practice may or may not agree to restrict the use or disclosure of your protected health information.
If this practice agrees to your request, the restriction will be binding on the practice. Use or disclosure of protected information in violation of an agreed upon restriction will be violation of the federal privacy standards.
You may revoke this consent to the use and disclosure of your protected health information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected.
Stephen J Harkins, DDS, PC DBA Harkins Pain & Sleep Management Group reserves the right to modify the privacy practices outlined in this notice.