Patient Information Form

Release of Medical Information Form

Your Health Information Form

NOTICE OF PRIVACY PRACTICES

As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

Our practice is dedicated to maintaining the privacy of your individually identifiable health information (IIHI). By federal and state law, we must follow the terms of the notice of privacy practices that we have in effect at the time.

WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION (IIHI) IN THE FOLLOWING WAYS

• Treatment. Our practice may use your IIHI to treat you, or disclose your IIHI to other health care providers for purposes related to your treatment.

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• Payment. Our practice may use and disclose your IIHI in order to bill and collect payment for the services and items you may receive from us. Also, we may use your IIHI to bill you directly for services and items. We may disclose your IIHI to other health care providers and entities to assist in their billing and collection efforts.

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• Health Care Operations. Our practice may use and disclose your IIHI to operate our business. We may disclose your IIHI to other health care providers and entities to assist in their health care operations.

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• Appointment Reminders. CareNet may use and disclose your IIHI to contact you regarding appointment (s) or other TPO items mail (home/work), voice mail (home/work), e-mail (home/work) and other. You let us know if you want restrictions regarding this item.

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• Health-Related Benefits and Services. Our practice may use and disclose your IIHI to inform you of health-related benefits or services that may be of interest to you.

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• Release of Information to Family/Friends. With your permission, our practice may release your IIHI to a friend or family member that is involved in your care, or who assists in taking care of you.

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• Disclosures Required By Law. Our practice will use and disclose your IIHI when we are required to do so by federal, state or local law.

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• Public Health Risks. Our practice may disclose your IIHI to public health authorities that are authorized by law to collect information.

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• Health Oversight Activities. Our practice may disclose your IIHI to a health oversight agency for activities authorized by law. Other activities necessary for the government to monitor government programs, compliance with civil rights laws and the health care system in general.

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• Lawsuits and Similar Proceedings. Our practice may use and disclose your IIHI in response to a court or administrative order, if you are involved in a lawsuit or similar proceeding.

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• Law Enforcement. We may release IIHI if asked to do so by a law enforcement official.

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• Deceased Patients. Our practice may release IIHI to a medical examiner or coroner to identify a deceased individual or to identify the cause of death. If necessary, we also may release information order for funeral directors to perform their jobs.

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• Organ and Tissue Donation. Our practice may release your IIHI to organizations that handle organ, eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or tissue donation and transplantation if you are organ donor.

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• Serious Threats to Health or Safety. Our practice may use and disclose your IIHI when necessary to reduce or prevent a serious threat to your health and safety or the health safety of another individual or the public.

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• Military. Our practice may disclose your IIHI if you are a member of US or foreign military forces (including veterans) and if required by the appropriate authorities.

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• National Security. Our practice may disclose your IIHI to federal officials for intelligence and national security activities authorized by law.

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• Inmates. Our practice may disclose your IIHI to correctional institutions or law enforcement officials if you are an inmate or under the custody of a law enforcement official.

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• Workers' Compensation. Our practice may release your IIHI for workers' compensation and similar programs.

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You have the following rights regarding the IIHI that we maintain about you.

• Confidential Communications. You have the right to request that our practice communicate with you about your health and related issues in a particular manner or at a certain location. Our practice will accommodate reasonable requests. You do not need to give a reason for your request.
• Requesting Restrictions. You have the right to request a restriction in our use or disclosure of your IIHI for treatment, payment or health care operations. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat you.
• Inspection and Copies. You have the right to inspect and obtain a copy of the IIHI that may be used to make decisions about you. You must submit your request in writing. Our practice will charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances.
• Amendment. You may ask us to amend in wrting that your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice.
• Accounting of Disclosures. All of our patients have the right to request an "accounting" of disclosures.
• Right to a Paper Copy of This Notice. You are entitled to receive a paper copy of our notice of privacy practices and the copy of the Privacy Policy.
• Right to File a Complaint. If you believe your privacy rights have been violated you may file a complaint with our practice or with the privacy officer.

IF YOU HAVE QUESTIONS REGARDING THIS POLICY PLEASE CONTACT US.