We use health information about you for treatment, to obtain payment for treatment, for administrative purposes and to evaluate the quality of care that you recieve.
We may use or disclose identifiable health information about you without your authorization for several other reasons. Subject to certain requirements, we may give out healt information without your authorization for public health purposes, for auditing purposes, for research studies, and for emergencies. We provide information when otherwise required by law, such as law enforcement in specific circumstances. In any other situation, we will ask you for written authorization before using or disclosing any identifiable health information about you. If you choose to sign this authorization, you can later revoke that authorization to stop any future uses and disclosures.
We may change our policies at any time. Before we make a significant change in our policies, we will change our notice and post the new notice in the waiting area. You can also request a copy of our new notice at any time.
In most cases, you have the right to look at or get a copy of health information about you that we use to make decisions about you. You also have the right to recieve a list of instances where we have disclosed health information about you for reasons other than treatment, payment or related administrative purposes. If you believe that information in your record is incorrect or if the important information is missing, you have the right to request that we correct the existing information or add the missing information.
You may request in writing that we not use or disclose your information for treatment, payment and administrative purposes except when specifically authorized by you, when required by law, or in emergency circumstances.
If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact the practice administrator. You may also send a written complaint to the U.S. Department of Human Services.
We are required by law to protect the privacy of your information, provide this notice about our information practices, and follow the information practices that are described in this notice.
Signature: ___________________________________________________ Date: _____________________________
Account Number: _____________________________________________________