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July 12, 2005
Notice of Privacy Policy
ARTHRITIS ASSOCIATES, PLLC
NOTICE OF PRIVACY PRACTICES
FOR PROTECTED HEALTH INFORMATION
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU MAY GET ACCESS TO THIS INFORMATION. PLEASE READ IT CAREFULLY.
Arthritis Associates, PLLC (The Practice) is dedicated to protecting your medical information (or Protected Health Information). We are required by law to maintain the privacy of protected health information and to provide you with this notice of our legal duties and privacy practices with respect to Protected Health Information. We are required by law to abide by the terms of this Notice, making any revision applicable to all of the protected health information we maintain. If we revise the terms of this Notice, we will post a revised notice at the Office and will make paper copies of this Notice of Privacy Practices. Your protected health information is available for review upon request.
HOW YOUR MEDICAL INFORMATION WILL BE USED AND DISCLOSED:
We will use your protected health information as part of rendering patient care. For example, your protected health information may be used by the health care professional treating you, by the business office to process your payment for the services rendered, and by our staff reviewing the quality and appropriateness of the care received. We may also use and/or disclose your information in accordance with federal/state laws for the following:
·Unless you object, we may disclose to family members, other relatives, or close personal friends the medical information directly relevant to such person’s involvement with your care.
·Unless you object, we may use or disclose your medical information to notify a family member, or other person responsible for your care of our location and your general condition, or death.
·We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits that may be of interest to you.
·We may disclose medical information when required by the U.S. Department of Health and Human Services as part of an investigation or determination of the Practice’s compliance with relevant laws.
·We may use or disclose your medical information for public health activities, including the reporting of disease, injury, and the conduct of public health surveillance. We may disclose your medical information concerning abuse, neglect, or violence in accordance with federal and state law.
·We may disclose your medical information in the course of certain judicial or administrative proceedings.
·We may disclose your medical information for law enforcement purposes or other specialized governmental functions.
·We may disclose your medical information to a coroner, medical examiner, or funeral director.
·If you are an organ donator, we may disclose your medical information to an organ donation and procurement organization.
·We may use or disclose your medical information for certain research purposes.
·We may use or disclose your medical information to prevent or lessen a serious threat to health and safety of another or the public.
·We may disclose your medical information as authorized by laws relating to Workers Compensation or other programs.
We will not use or disclose your medical information for any other purpose without your written authorization. Once given, you can revoke your authorization at any time.
If you need an explanation of any of these uses, please ask the receptionist.
YOUR RIGHTS REGARDING YOUR MEDICAL INFORMATION
You have the following rights with respect to your medical information:
·The right to request restrictions on certain uses and disclosures of your Protected Health Information. We are not required to agree to your requested restriction, but if we do, we will honor it.
·The right to receive communications from us in a confidential manner.
·The right to inspect and copy your medical information. This right is subject to certain specific exceptions and you may be charged a reasonable fee for any copies of your records.
·The right to request an amendment of your medical information. We may deny your request for certain specific reasons, and, if denied, we will provide you with written explanation for the denial and information regarding further rights you would have at that point.
·The right to receive an accounting of the disclosures of your medical information in the six years prior to your request (following April 14, 2003), except for disclosures for treatment, payment, or practice operational purposes, disclosures pursuant to an authorization and certain other specific disclosure types.
·The right to request a paper copy of this Notice of Privacy Practices for Protected Health Information.
·The right to complain to the Practice and/or to the U.S. Department of Health and Human Services, if you believe that the Practice has violated your privacy rights. To complain to the Practice, please call:
Compliance Officer at (601) 582-7655
If you choose to file a complaint, you will not be retaliated against in any way.
THIS NOTICE IS EFFECTIVE APRIL 14, 2003.
I have received a copy of this notice and have had an opportunity to ask questions concerning the Practice’s Notice of Privacy Practices for Protected Health Information.
_____________________________________________ ____________________________
Patient or Patient’s Representative Date
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