HIPAA NOTICE OF PRIVACY
PRACTICES
I. 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.
II. IT IS MY
By law I am required to insure that your PHI is kept private. The PHI constitutes information created or
noted by me that can be used to identify you.
It contains data about your past, present, or future health or
condition, the provision of health care services to you, or the payment for
such health care. I am required to
provide you with this Notice about my privacy procedures. This Notice must
explain when, why, and how I would use and/or disclose your PHI. Use of PHI means when I
share, apply, utilize, examine, or analyze information within my practice; PHI is disclosed
when I release, transfer, give, or otherwise reveal
it to a third party outside my practice. With some exceptions, I may not use or
disclose more of your PHI than is necessary to accomplish the purpose for which
the use or disclosure is made; however, I am always legally required to follow the privacy
practices described in this Notice.
Please note that I reserve the right to change the terms of this
Notice and my privacy policies at any time.
Any changes will apply to PHI already on file with me. Before I make any important changes to my
policies, I will immediately change this Notice and post a new copy of it in my
office and on my website www.nhgv.org. You may also request a copy of
this Notice from me, or you can view a copy of it in my office or on my
website, which is located at www.nhgv.org.
III.
HOW I WILL USE
I will use and disclose your
A. Uses and Disclosures Related to Treatment, Payment, or
Health Care Operations Do Not Require Your Prior Written Consent. I
may use and disclose your PHI without your consent for the following reasons:
1. For treatment. I may disclose your
2. For health care operations. I may disclose your PHI to facilitate the efficient
and correct operation of my practice. Examples:
Quality control - I might use your PHI in the evaluation of the quality
of health care services that you have received or to evaluate the performance
of the health care professionals who provided you with these services. I may also provide your PHI to my attorneys,
accountants, consultants, and others to make sure that I am in compliance with
applicable laws.
3. To obtain payment for
treatment. I may use and
disclose your PHI to bill and collect payment for the treatment and services I
provided you. Example: I might send your PHI to your insurance company or
health plan in order to get payment for the health care services that I have
provided to you. I could also provide your PHI to business associates, such as
billing companies, claims processing companies, and others that process health
care claims for my office.
4. Other disclosures. Examples: Your
consent isn't required if you need emergency treatment provided that I attempt
to get your consent after treatment is rendered. In the event that I try to get
your consent but you are unable to communicate with me (for example, if you are
unconscious or in severe pain) but I think that you would consent to such
treatment if you could, I may disclose your PHI.
B. Certain Other Uses and Disclosures Do Not Require Your Consent. I may use
and/or disclose your PHI without your consent or authorization for the
following reasons:
1.
When disclosure is required by federal,
state, or local law; judicial, board, or administrative proceedings; or, law
enforcement. Example: I may
make a disclosure to the appropriate officials when a law requires me to report
information to government agencies, law enforcement personnel and/or in an
administrative proceeding.
2.
If disclosure is compelled by a party
to a proceeding before a court of an administrative agency pursuant to its
lawful authority.
3.
If disclosure is required by a search
warrant lawfully issued to a governmental law enforcement agency.
4.
If disclosure is compelled by the
client or the client’s representative pursuant to New York Health and Safety
Codes or to corresponding federal statutes of regulations, such as the Privacy Rule that requires this Notice.
5.
To avoid harm. I may provide
6.
If disclosure is compelled or permitted
by the fact that you are in such mental or emotional condition as to be
dangerous to yourself or the person or property of others, and if I determine
that disclosure is necessary to prevent the threatened danger.
7.
If disclosure is mandated by the New
York Child Abuse and Neglect Reporting law. For example,
if I have a reasonable suspicion of child abuse or neglect.
8.
If disclosure is mandated by the New
York Elder/Dependent Adult Abuse Reporting law. For example,
if I have a reasonable suspicion of elder abuse or dependent adult abuse.
9.
If disclosure is compelled or permitted
by the fact that you tell me of a serious/imminent threat of physical violence
by you against a reasonably identifiable victim or victims.
10. For
public health activities. Example: In the event of your death, if a disclosure
is permitted or compelled, I may need to give the county coroner information
about you.
11. For
health oversight activities. Example: I may be required to provide information to
assist the government in the course of an investigation or inspection of a
health care organization or provider.
12. For
specific government functions. Examples: I may disclose PHI of military personnel
and veterans under certain circumstances. Also, I may disclose PHI in the
interests of national security, such as protecting the President of the United
States or assisting with intelligence operations.
13. For
research purposes. In certain
circumstances, I may provide PHI in order to conduct medical research.
14. For
Workers' Compensation purposes. I may provide PHI in order to comply with Workers' Compensation laws.
15. Appointment
reminders and health related benefits or services. Examples: I may use PHI to provide appointment
reminders. I may use PHI to give you information about alternative treatment
options, or other health care services or benefits I offer.
16. If
an arbitrator or arbitration panel compels disclosure, when arbitration is lawfully requested by either
party, pursuant to subpoena duces tectum
(e.g., a subpoena for mental health records) or any other provision authorizing
disclosure in a proceeding before an arbitrator or arbitration panel.
17. I
am permitted to contact you, without your prior authorization, to provide
appointment reminders or information about alternative or other heath-related
benefits and services that may be of interest to you.
18. If
disclosure is required or permitted to a health oversight agency for oversight
activities authorized by law. Example: When compelled by U.S. Secretary of Health
and Human Services to investigate or assess my compliance with HIPAA
regulations.
19. If
disclosure is otherwise specifically required by law.
C. Certain Uses and Disclosures Require You to Have the Opportunity to
Object.
1. Disclosures to family, friends, or
others. I may provide your PHI to a
family member, friend, or other individual who you indicate is involved in your
care or responsible for the payment for your health care, unless you object in
whole or in part. Retroactive consent
may be obtained in emergency situations.
D. Other Uses and Disclosures Require Your Prior Written Authorization. In any
other situation not described in Sections IIIA, IIIB, and IIIC above, I will
request your written authorization before using or disclosing any of your PHI.
Even if you have signed an authorization to disclose your PHI, you may later
revoke that authorization, in writing, to stop any future uses and disclosures
(assuming that I haven't taken any action subsequent to the original
authorization) of your PHI by me.
IV.
WHAT RIGHTS YOU HAVE REGARDING YOUR
These are your rights with respect
to your
A. The Right to See and Get Copies of
Your
If
you ask for copies of your
B. The Right to Request Limits on Uses
and Disclosures of Your
C. The Right to Choose How I Send Your
PHI to You. It is your right to ask
that your PHI be sent to you at an alternate address (for example, sending
information to your work address rather than your home address) or by an
alternate method (for example, via email instead of by regular mail). I am
obliged to agree to your request providing that I can give you the PHI, in the
format you requested, without undue inconvenience.
D. The Right to Get a List of the
Disclosures I Have Made. You are
entitled to a list of disclosures of your PHI that I have made. The list will
not include uses or disclosures to which you have already consented, i.e.,
those for treatment, payment, or health care operations, sent directly to you,
or to your family; neither will the list include disclosures made for national
security purposes, to corrections or law enforcement personnel, or disclosures
made before April 15, 2003. After April
15, 2003, disclosure records will be held for six years.
I
will respond to your request for an accounting of disclosures within 60 days of
receiving your request. The list I give you will include disclosures made in
the previous six years (the first six year period being 2003-2009) unless you
indicate a shorter period. The list will include the date of the disclosure, to
whom PHI was disclosed (including their address, if known), a description of the
information disclosed, and the reason for the disclosure. I will provide the
list to you at no cost, unless you make more than one request in the same year,
in which case I will charge you a reasonable sum based on a set fee for each
additional request.
E. The Right to Amend Your
F. The Right to Get This Notice by
Email You have the right to get this
notice by email. You have the right to request a paper copy of it, as well.
V.
HOW TO COMPLAIN ABOUT MY PRIVACY PRACTICES
If,
in your opinion, I may have violated your privacy rights, or if you object to a
decision I made about access to your PHI, you are entitled to file a complaint
with the person listed in Section VI below. You may also send a written
complaint to the Secretary of the Department of Health and Human Services at
VI. PERSON TO CONTACT FOR INFORMATION ABOUT THIS NOTICE OR TO COMPLAIN
ABOUT MY PRIVACY PRACTICES
If
you have any questions about this notice or any complaints about my privacy
practices, or would like to know how to file a complaint with the Secretary of
the Department of Health and Human Services, please contact me at:
Dr. Mark Spezzano
3 Episcopal Avenue
(585) 624 – 1350
This notice went into effect on
I acknowledge receipt of this notice
Patient Name:
_______________________
Signature:
_________________________ Date:
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Patient Name:
_______________________
Signature:
_________________________ Date:
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Patient Name:
_______________________
Signature: _________________________ Date:
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