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(Please refer to §164.520 of the Federal Register

for HIPAA Rules and Regulations for all required elements.)


We may use your health information, information that constitutes protected health information as defined in the Privacy Rule of the Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996, for purposes of providing you treatment, obtaining payment for your care and conducting health care operations.  We have established policies to guard against unnecessary disclosure of your health information.


To Provide Treatment.  Our office may use your health information to coordinate care within the practice and with others involved in your care.  For example, physicians involved in your care will need information about your symptoms in order to prescribe appropriate medications.   We also may disclose your health care information to individuals outside of our practice involved in your care including family members, pharmacists, suppliers of medical equipment, or other health care professionals.

To Obtain Payment.  We may include your health information in invoices to collect payment from third parties for the care you received.  For example, we may be required by your health insurer to provide information regarding your health care status so that the insurer will reimburse you or our office.  We also may need to obtain prior approval from your insurer and may need to explain to the insurer your need for health care that will be provided to you.

To Conduct Health Care Operations.  We may use and disclose health information for its own operations in order to facilitate our services and as necessary to provide quality care to all of our patients.  Health care operations includes such activities as:

  •  Quality assessment and improvement activities.
  • Activities designed to improve health or reduce health care costs.
  • Protocol development, case management and care coordination.
  • Contacting us and our patients with information about treatment alternatives and other related functions that do not include treatment.
  • Professional review and performance evaluation.
  • Training programs including those in which students, trainees or practitioners in health care learn under supervision.
  • Training of non-healthcare professionals.
  • Accreditation, certification, licensing, or credentialing activities.
  • Review and auditing, including compliance reviews, medical reviews, legal services, and compliance programs.
  • Business planning and development including cost management and planning-related analyses and formulary development.
  • Business management and general administrative activities.

For example, we may use your health information to evaluate its staff performance, combine your health information with our other patients in evaluating how to more effectively serve all of our patients, disclose your health information to staff and contracted personnel for training purposes, use your health information to contact you as a reminder regarding a visit to you, or contact you as part of general fundraising and community information mailings (unless you tell us you do not want to be contacted).

For Appointment Reminders.  We may use and disclose your health information to contact you as a reminder that you have an appointment for a doctor’s office visit.

For Treatment Alternatives.  We may use and disclose your health information to tell you about or recommend possible treatment options or alternatives that may be of interest to you.


When Legally Required.  We will disclose your health information when it is required to do so by any Federal, State, or local law.

When There Are Risks to Public Health.  We may disclose your health information for public activities and purposes in order to.

  • Prevent or control disease, injury, or disability, report disease, injury, and vital events such as birth or death, and conduct public health surveillance, investigations, and interventions.
  • Report adverse events, and product defects, to track products or enable product recalls, repairs, and replacements and to conduct post-marketing surveillance and compliance with requirements of the Food and Drug Administration.
  • Notify a person who has been exposed to a communicable disease or who may be at risk of contracting or spreading a disease.
  • Notify an employer about an individual who is a member of the workforce as legally required.

To Report Abuse, Neglect Or Domestic Violence.  Our practice is allowed to notify government authorities if we believe a patient is the victim of abuse, neglect or domestic violence. We will make this disclosure only when specifically required or authorized by law or when the patient agrees to the disclosure.

To Conduct Health Oversight Activities.  We may disclose your health information to a health oversight organization for activities including audits, civil, administrative or criminal investigations, inspections, licensure or disciplinary action.  However, we may not disclose your health information if you are the subject of an investigation and your health information is not directly related to your receipt of health care or public benefits.

In Connection With Judicial And Administrative Proceedings. We may disclose your health information in the course of any judicial or administrative proceeding in response to an order of a court or administrative tribunal as expressly authorized by such order or in response to a subpoena, discovery request, or another lawful process, but only after we make reasonable efforts to either notify you about the request or to obtain an order protecting your health information.

For Law Enforcement Purposes.  As permitted or required by State law, we may disclose your health information to a law enforcement official for certain law enforcement purposes as follows:

  • As required by law for reporting of certain types of wounds or other physical injuries pursuant to the court order, warrant, subpoena or summons or similar process.
  • For the purpose of identifying or locating a suspect, fugitive, material witness or missing person.
  • Under certain limited circumstances, when you are the victim of a crime.
  • To a law enforcement official if we have a suspicion that your death was the result of criminal conduct including criminal conduct at our office.
  • In an emergency in order to report a crime.

To Coroners And Medical Examiners. We may disclose your health information to coroners and medical examiners for purposes of determining your cause of death or for other duties, as authorized by law.

To Funeral Directors.  We may disclose your health information to funeral directors consistent with applicable law and if necessary, to carry out their duties with respect to your funeral arrangements.  If necessary to carry out their duties, We may disclose your health information prior to and in reasonable anticipation of your death.

For Organ, Eye, Or Tissue Donation.  We may use or disclose your health information to organ procurement organizations or other entities engaged in the procurement, banking or transplantation of organs, eyes, or tissue for the purpose of facilitating the donation and transplantation.

For Research Purposes.  Our office may, under very select circumstances, use your health information for research.  Before Our office discloses any of your health information for such research purposes, the project will be subject to an extensive approval process.  [If we intend to conduct research it is important to carefully review the authorization requirements for research exceptions and revise the Notice provisions as needed.]

In the Event of A Serious Threat To Health Or Safety.  Our office may, consistent with applicable law and ethical standards of conduct, disclose your health information if we, in good faith, believes that such disclosure is necessary to prevent or lessen a serious and imminent threat to your health or safety or to the health and safety of the public.

For Specified Government Functions.  In certain circumstances, the Federal regulations authorize Our office to use or disclose your health information to facilitate specified government functions relating to military and veterans, national security and intelligence activities, protective services for the President and others, medical suitability determinations and inmates and law enforcement custody.

For Worker’s Compensation.  We may release your health information for worker’s compensation or similar programs.


Other than is stated above, we will not disclose your health information other than with your written authorization.  If you or your representative authorizes Our office to use or disclose your health information, you may revoke that authorization in writing at any time.


You have the following rights regarding your health information that our office maintains:

Right to request restrictions.  You may request restrictions on certain uses and disclosures of your health information.  You have the right to request a limit on our disclosure of your health information to someone who is involved in your care or the payment of your care.  However, we are not required to agree to your request.  If you wish to make a request for restrictions, please contact this office.

Right to receive confidential communications.  You have the right to request that we communicate with you in a certain way.  For example, you may ask that we only conduct communications pertaining to your health information with you privately with no other family members present.  If you wish to receive confidential communications, please advise us in writing   We will not request that you provide any reasons for your request and will attempt to honor your reasonable requests for confidential communications.

Right to inspect and copy your health information.  You have the right to inspect and copy your health information, including billing records.    If you request a copy of your health information, we may charge a reasonable fee for copying and assembling costs associated with your request.

Right to amend health care information.  You or your representative have the right to request that we amend your records, if you believe that your health information is incorrect or incomplete.  That request may be made as long as the information is maintained.  A request for an amendment of records must be made in writing and submitted to our office.  We may deny the request if it is not in writing or does not include a reason for the amendment.  The request also may be denied if your health information records were not created by us or if the records you are requesting are not part of our office records, if the health information you wish to amend is not part of the health information you or your representative are permitted to inspect and copy, or if, in our opinion the records containing your health information are accurate and complete.

Right to an accounting.  You or your representative have the right to request an accounting of disclosures of your health information for certain reasons, including reasons related to public purposes authorized by law and certain research. The request for an accounting must be made in writing to our office.  The request should specify the time period for the accounting starting on or after a date certain.   Accounting requests may not be made for periods of time in excess of six (6) years.  We will provide the first accounting you request during any 12-month period without charge.  Subsequent accounting requests may be subject to a reasonable cost-based fee.

Right to a paper copy of this notice.  You or your representative have a right to a separate paper copy of this Notice at any time even if you or your representative have received this Notice previously.  To obtain a separate paper copy, please contact us.


We are required by law to maintain the privacy of your health information and to provide to you and your representative this Notice of its duties and privacy practices.  We are required to abide by the terms of this Notice as may be amended from time to time.  We reserve the right to change the terms of this Notice and to make the new Notice provisions effective for all health information that it maintains.  If we change this Notice, we will provide a copy of the revised Notice to you or your appointed representative.  You or your personal representative have the right to express complaints to our office and to the Secretary of the United States Department of Health and Human Services if you or your representative believe that your privacy rights have been violated.  Any complaints to the Secretary of the United States Department of Health and Human Services should be made in writing to 200 Independence Avenue, S.W., Washington, D.C. 20201, (202) 619-0257.

We encourage you to express any concerns you may have regarding the privacy of your information.  You will not be retaliated against in any way for filing a complaint.