Effective April 14, 2003

Our Pledge Regarding Health Information:

We understand that health information about you and your health care is personal. We are committee to protecting health information about you. We create a record of the care and services you receive from us. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated by this health care practice, whether made by your personal doctor or others working in this office. This notice will tell you about the ways in which we may use and disclose health information about you. We also describe your rights to the health information we keep about you, and describe certain obligations we have regarding the use and disclosure of your health information.

We are required by law to:

  • Make sure that health information that identifies you is kept private
  • Give you this notice of our legal duties and privacy practices with respect to health information about you
  • Follow the terms of the notice that is currently in effect

Below is a partial listing of how we may use and disclose health information about you. For the full documentation, please
ask our receptionist for our full privacy policy.

  • For treatment
  • For payment
  • For health care operations
  • Appointment reminders
  • Research
  • As required by law
  • To avert a serious threat to health or safety

Your Rights Regarding Health Information About You

  • Inspect and Copy
  • Amend
  • Account for Disclosures
  • Request Restrictions
  • Request Confidential Communications
  • Receive a paper copy of this notice

Changes to this Notice: We reserve the right to change this notice and to make the revised or changed notice effective for health information we already have about you as well as any information we may receive in the future. We will post a copy of the current notice in our facility.

Complaints: If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of the Department of Health and Human Services. Please contact Marsha Pinat, office administrator if you have questions regarding this. All complaints are to be submitted in writing. You will not be penalized for filing a complaint.

Other uses of Health Information: Any other uses of health information not covered in this notice will be made only with your written permission. If you’ve given written permission, you may revoke that permission, in writing, at any time. (See the full copy of this notice for further information regarding this.)