To make your visit less time consuming, we ask that you fill out and
print the Patient Information and Medical History Forms.
Please bring the completed forms with you when you come in for your
appointment. Filling out these forms will enable us to serve you better
1. Patients can print the Patient
Information and Medical History Forms and complete them with a
black ink pen oryou can download and install Adobe
Acrobat Reader which will enable you to fill out the Patient
Information and Medical History Forms or any .PDF formright
on your computer before printing them.
2. 3. Get Adobe Acrobat Reader
OF PRIVACY PRACTICES
Effective date: April 14, 2003
We understand that health information about you and your
health is personal. We are committed to protecting health information
about you. We create a record of the care and services your 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 office, 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
Follow the terms of the Notice that
is currently in effect.
How we may use and disclose health information about you:
For health care operations.
For appointment reminders.
As required by law.
To avert a serious threat to health
As required by the Military or
Veterans and Workers Compensation.
Public Health risks.
Health oversight activities.
Lawsuits and disputes.
Coroners, health examiners and
National Security and Intelligence
Protective Services for the
President and others.
Security Officials for Inmates.
Your rights regarding Health Information about you:
Right to inspect and copy.
Right to amend.
Right to an Accounting of
Right to Request Restrictions.
Right to Request Confidential
Right to a Paper copy of this
Notice (full Notice is available upon request).
Changes to this Notice:
We reserve the right to change this Notice. We will post a
copy of the current notice in our facility with the current effective
date on the first page.
If you believe that your privacy rights have been violated,
you may file a complaint with us. All complaints must be in writing.
Please contact the administrator at the location where you were treated
to file a complaint.
Acknowledgement of Receipt of this Notice:
We will request that you sign a separate form acknowledging
you have received a copy of this notice. This acknowledgement will
become a part of you records.
We may use and disclose your information to conduct or
arrange for services including:
Medical quality review by your
Accounting, legal, risk management,
and insurance services.
Audit functions, including fraud
and abuse detection and compliance programs.
Your Health Information Rights:
The health and billing records we create and store are the
property of the practice/health care facility. The protected health
information in it, however, generally belongs to you. You have the
Receive, read, and ask questions
about this Notice.
Ask us to restrict certain uses and
disclosures. You must deliver this request in writing to us. We are not
required to grant the request, but we will comply with any request
Request and receive from us a paper
copy of this or the most current Notice o Privacy Practices for
protected Health Information (“Notice”).
Request that you be allowed to see
and get a copy of your protected health information. You may make this
request in writing. We have a form available for this type of request
Have us review a denial of access
to your health information—except in certain circumstances.
Ask us to change your health
information. You may give us this request in writing. You may write a
statement of disagreement if your request is denied. It will be stored
in your medical record, and included with any release of your records.
When you request, we will give you
a list of disclosures of your health information. The list will not
include disclosures to third-party payors. You may receive this
information without charge once every 12 months. We will notify you of
the cost involved if you request this information more than once in 12
Ask that your health information be
given to you by another means or at another location. Please sign, date
and give us your request in writing.
Cancel prior authorizations to use
or disclose health information by giving us a written revocation. Your
revocation does not affect information that has already been released.
It also does not affect any action taken before we have it. Sometimes,
you cannot cancel an authorization if its purpose was to obtain
For help with these rights during normal business hours,
please contact the administrator of the location at which you have been
treated. Please call the main office phone number and ask for the
We are required to:
Keep your protected health
Give you this Notice.
Follow the terms of this notice.
We have the right to change our
practices regarding the protected health information we maintain. If we
make changes, we will update this Notice. You may receive the most
recent copy of this Notice by calling and asking for it or by visiting
our office to pick on up.
To Ask for Help or Complain
If you have questions, want more
information, or want to report a problem about the handling of your
protected health information, you may contact the administrator
of the location at which you have been treated. Pleas call the main
office phone number and ask for the administrator.
If you believe your privacy rights
have been violated, you may discuss your concerns with any staff
member. You may also deliver a written complaint to the administrator
at you practice/health care facility. You may also file a complaint
with the U.S. Secretary of Health and Human Services.
We respect your right to file a
complaint with us or with the U.S. Secretary of Health and Human
Services. If you complain, we will not retaliate against you.
Other Disclosures and Uses of Protected Health
Notification of Family and Others
Unless you object, we may release
health information about you to a friend or family member who is
involved in your medical care. We may also give information to someone
who helps pay for your care. We may tell your family or friends your
condition and that you are in a hospital. In addition, we may disclose
health information about you to assist in disaster relief efforts.
You have the right to object to
this use or disclosure of you information. If you object, we will not
use or disclose it.
We may use and disclose your protected health
information without your authorization as follows:
With Medical Researchers—if
the research has been approved and has policies to protect the privacy
of your health information. We may also share information with medical
researches preparing to conduct a research project.
To Funeral Directors/Coroners consistent
with applicable law to allow them to carry out their duties.
To Organ Procurement
Organizations (tissue donation and transplant) or persons who
obtain, store, or transplant organs.
To the Food and Drug
Administration (FDA) relating to problems with food, supplements,
To Comply with Workers’
Compensation Laws—If you make a workers’ compensation
For Public Health and Safety
Purposes as Allowed or Required by Law:
to prevent or reduce a serious,
immediate threat to the health or safety of a person.
or the public.
to public health or legal
to protect public health and safety.
to prevent or control disease,
injury, or disability.
to report vital statistics such as
births or deaths.
To Report Suspected Abuse or
Neglect to public authorities.
To Correctional Institutions if
you are in jail or prison, as necessary for your health and the health
and safety of others.
For Law Enforcement Purposes such
as when we receive a subpoena, court order, or other legal process, or
you are the victim of a crime.
For Health and Safety Oversight
Activities. For example, we may share health information with the
Department of Health.
For Disaster Relief Purposes. For
example, we may share health information with disaster relief agencies
to assist in notification of your condition to family or others.
For Work-Related Conditions That
Could Affect Employee Health. For example, and employer may ask us
to assess health risks on a job site.
To the Military Authorities of
U.S. and Foreign Military Personnel. For example, the law may
require us to provide information necessary to a military mission.
In the Course of
Judicial/Administrative Proceedings at your request, or as
directed by a subpoena or court order.
For Specialized Government
Functions. For example, we may share information for national
Other Uses and Disclosures of Protected Health
Uses and disclosures not in this
Notice will be made only as allowed or required by law or with your