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HIPAA Notice of Privacy Practices
Stuart Lipton, M.D.
Lewisville Surgery Center
591 W. Main Street
Lewisville, TX 75057
972-420-0023
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This notice describes how medical information about you may be
used and disclosed and how you can get access to this information.
Please review it careful.
This
Notice of Practices describes how we may use and disclose your
protected
health information (PHI) to carry out treatment,
payment or health care operations (TPO) and for other purposes
that are permitted or required by law. It also describes your rights
to access and control your protected health information. “Protected
health information” is information about you, including demographic
information, that may identify you and that relates to your past,
present or future physical or mental health or condition and related
health care services.
1. Uses and Disclosures of Protected Health Information
Uses and Disclosures or Protected Health Information
Your protected health information may be used and disclosed by
your physician, our office staff and others outside of our office
that are involved in your care and treatment for the purpose
of providing health care services to you, to pay your health
care bills, to support the operation of the physician’s
practice, and any other use required by law.
Treatment: We will use and disclose your protected health information
to provide, coordinate, or manage your health care and any related
services. This included the coordination or management of your
health care with a third party. For example, we would disclose
your protected health information, as necessary, to a home health
agency that provides care to you. For example, your protected health
information may be provided to a physician to whom you have been
referred to ensure that the physician has the necessary information
to diagnose or treat you.
Payment: Your protected health information will be used, as needed,
to obtain payment for your health care services. For example, obtaining
approval for a hospital stay may require that your relevant protected
health information be disclosed to the health plan to obtain approval
for the hospital admission.
Healthcare
Operations: We may use or disclose, as-needed, your protected
health information in order to support the business activities
of your physician’s practice. These activities include, but
are not limited to, quality assessment activities, employee review
activities, training of medical students, licensing, and conducting
or arranging for other business activities. For example, we may
disclose your protected health information to medical school students
that see patients at our office. In addition, we may use a sign-in
sheet at the registration desk where you will be asked to sign
your name and indicate your physician. We may also call you by
name in the waiting room when you r physician is ready to see you.
We may use or disclose your protected health information, as necessary,
to contact you to remind you of your appointment.
We
may use or disclose your protected health information in the
following
situations without your authorization. These situations
include: as Required By Law, health issues as required by law,
Communicable Diseases: Health Oversight: Abuse or Neglect: Food
and Drug Administration requirements: Legal Proceedings: Law Enforcement:
Coroners, Funeral Directors, and Organ Donation: Research Criminal
Activity: Military Activity and National Security: Workers’ Compensation:
Inmates: Required Use and Disclosures: Under the law, we must make
disclosures to you and when required by the Secretary of the Department
of Health and Human Services to investigate or determine our compliance
with the requirements of Section 164.500
Other
Permitted and Required Uses and Disclosures: Will be Made
Only With Your Consent. Authorization or Opportunity to Object
unless required by law.
You
may revoke this authorization: at any time, in writing, except
to the extent
that your physician or the physician’s practice
has taken an action in reliance on the use or disclosure indicated
in the authorization.
Your Rights
Following is a statement of your rights with respect to your protected
health information.
You
have the right to inspect and copy your protected health information.
Under Federal law, however, you may not inspect or copy the following
records; psychotherapy notes; information compiled in reasonable
anticipation of, or use in, a civil, criminal, or administrative
action or proceeding, and protected health information that is
subject to law that prohibits access to protected health information.
You
have the right to request a restriction of your protected health
information. This means you may ask us not to use or disclose
any part of your protected health information not be disclosed
to family members or friends who may be involved in your care or
for notification purposes as described in this Notice of Privacy
Practices. Your request must state the specific restriction requested
and to whom you want the restriction to apply.
Your physician is not required to agree to a restriction that
you may request. If physician believes it is in your best interest
to permit use and disclosure of your protected health information,
your protected health information will not be restricted. You then
have the right to use another Healthcare Professional.
You
have the right to request to receive confidential communications
from us by alternative means or at an alternative location. You
have the right to obtain a paper copy of this notice from us. Upon
request, even if you have agreed to accept this notice alternatively
i.e. electronically.
You
may have the right to have your physician amend your protected
health information. If we deny your request for amendment, you
have the right to file a statement of disagreement with us and
we may prepare a rebuttal to your statement and will provide you
with a copy of and such rebuttal.
You
have the right to receive an accounting of certain disclosures
we have made, if any, of your protected health information.
We reserve the right to change the terms of this notice and will
inform you by mail of any changes. You then have the right to object
or withdraw as provided in this notice.
Complaints
You may complain to us or the Secretary of Health and Human Services
if you believe your privacy rights have been violated by us.
You may file a complaint with us by notifying our privacy contact
of your complaint. We will not retaliate against you
for filing a complaint.
This notice was published and become effective on/or before April
14, 2003.
We are required by law to maintain the privacy of, and provide
individuals with, this notice of our legal duties and privacy practices
with respect to a protected health information. If you have any
objections to this form, please ask to speak with our HIPAA Compliance
Officer in person or by phone at our Main Phone Number.
Signature below is only acknowledgement that you have received
this Notice of our Privacy Practices:
Print Name: _________________
Signature: _____________________
Date: _____
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