Notice of Privacy Practices
The Health Insurance Portability & Accountability
Act of 1996 ("HIPAA") is a Federal program that requests that all
medical records and other individually identifiable health information used or
disclosed by us in any form, whether electronically, on paper, or orally are
kept properly confidential. This Act gives you, the patient, the right to
understand and control how your personal health information ("PHI") is
used. HIPAA provides penalties for covered entities that misuse personal health
As required by HIPAA, we prepared this explanation of how
we are to maintain the privacy of your health information and how we may
disclose your personal information.
may use and disclose your medical records only for each of the following
purposes: treatment, payment and health care operation.
means providing, coordinating, or managing health care and related services by
one or more healthcare providers. An example of this is a primary care doctor
referring you to a specialist doctor.
means such activities as obtaining reimbursement for services, confirming
coverage, billing or collections activities, and utilization review. An example
of this would include sending your insurance company a bill for your visit
and/or verifying coverage prior to a surgery.
• Health Care Operations include business aspects of
running our practice, such as conducting quality assessments and improving
activities, auditing functions, cost management analysis, and customer service.
An example of this would be new patient survey cards.
• The practice may also be required or permitted to
disclose your PHI for law enforcement and other legitimate reasons. In all
situations, we shall do our best to assure its continued confidentiality to the
We may also create and distribute de-identified health
information by removing all reference to individually identifiable information.
We may contact you, by phone or in writing, to provide
appointment reminders or information about treatment alternatives or other health-related benefits
and services, in addition to other fundraising communications, that may be of interest to you. You do
have the right to "opt out" with respect to receiving fundraising communications from us.
The following use and disclosures of PHI will only be made
pursuant to us receiving a written authorization from you:
• Most uses and disclosure of psychotherapy notes;
• Uses and disclosure of your PHI for marketing purposes,
including subsidized treatment and health care operations;
• Disclosures that constitute a sale of PHI under HIPAA;
• Other uses and disclosures not described in this notice.
You may revoke such authorization in writing and we are
required to honor and abide by that written request, except to the extent that we have already taken
actions relying on your prior authorization.
You may have the following rights with respect to your
• The right to request restrictions on certain uses and
disclosures of PHI, including those related to disclosures of family members, other relatives, close
personal friends, or any other person identified by you. We are, however, not
required to honor a request restriction except in limited circumstances which
we shall explain if you ask. If we do agree to the restriction, we must abide
by it unless you agree in writing to remove it.
• The right to reasonable requests to receive confidential
communications of Protected Health
Information by alternative means or at alternative
• The right to inspect and copy your PHI.
• The right to amend your PHI.
• The right to receive an accounting of disclosures of
• The right to obtain a paper copy of this notice from us
• The right to be advised if your unprotected PHI is
intentionally or unintentionally disclosed.
If you have paid for services "out of pocket",
in full and in advance, and you request that we not disclose PHI related solely to those services to a health plan, we
will accommodate your request, except where we are required by law to make a disclosure.
We are required by law to maintain the privacy of your
Protected Health Information and to provide you
the notice of our legal duties and our privacy practice
with respect to PHI.
This notice if effective as of ________________________
and it is our intention to abide by the terms of the Notice of Privacy
Practices and HIPAA Regulations currently in effect. We reserve the right to change the terms of our Notice of Privacy Practice and to
make the new notice provision effective for all PHI that we maintain. We will post and you may request a
written copy of the revised Notice of Privacy
Practice from our office.
You have recourse if you feel that your protections have
been violated by our office. You have the right to file a formal, written complaint with office and with
the Department of Health and Human Services, Office of Civil Rights. We will not retaliate against you
for filing a complaint.
Feel free to contact the Practice Compliance Officer
(insert name and telephone number) for more information, in person or in writing.
(Copyright 2014 American Psychiatric Association and American Academy
of Dermatology Association. APA members have permission to use for personal practice.)