HIPPA Notice of Privacy Practices

This Notice of Privacy 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 or required by law. It also describes your rights to access and control your PHI. “PHI” is information about you, including demographic information, that may identify you, that relates to your past, present or future physical or mental health or condition and related health care services. 

1. Uses & disclosures of protected health information: Your PHI may be used and disclosed by your physician, our office staff, and others outside of our office that are involved in your care and for treatment 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.

Payments: Your PHI 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 PHI in order to support the business activities of your physicians 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 PHI to a medical students that see patients at our office. In addition, we may use a sign-in sheet at the front desk where you will be asked to sign your name and asked to specify your physician. We will also call you by name in the waiting room when your physician is ready to see you. We may also use your PHI as necessary to contact you about your appointments.

We may use or disclose your PHI in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as required by law, Communicable Diseases; Oversight: Abuse or Neglect; Food and Drug Administration requirements; Legal Proceedings; Law Enforcement: Coroners, Funeral Directors and Organ Donation; Research; Research; Criminal Activity; Military Activity and National Security; Workers’ Compensation; Inmates; Required Uses and Disclosures: Under the law, we must make disclosures to you when when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance 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: The following is a statement of your rights with respect to your Protected Health Information(PHI)

You have the right to inspect and copy your PHI. 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 PHI that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your PHI. This means you can ask us not to use or disclose any part of your PHI for the purpose of treatment, payment, or healthcare operations. You may also request that any part of your PHI not be disclosed to any 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 whom you want the restriction to apply.

Your physician is not required to agree to restriction that you may request. If the physician believes it is in your best interest to permit use and disclosure of your PHI, your PHI will not be restricted. You then have the right to use another healthcare professional.

You have the right to request and receive confidential communication 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 have the right to receive an accounting of certain disclosures we have made, if any, of your PHI.

We reserve the right to change terms of this notice and will inform you by mail of any changes. You then have the right to object or withdrawal as provided in this notice.


You may complain to us or to 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 complaints. We will not retaliate against you for filing a complaint.

This notice was published and becomes effective on/before April 14, 2003.

We are required by law to maintain the privacy and provide individuals with this notice of our legal duties and privacy practices with respect to PHI. If you have any objections to this form, please ask to speak with our HIPPA Compliance Officer in person or by phone at (530) 605-4555.