Notice of Privacy Practices

This notice describes how medical information about you may be used, disclosed, and how you can get access to this information. Please read carefully!

This Notice of Privacy Practices describes how we may use and disclosed your protected health information to carry out treatment, payment, healthcare operations, 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 we create and obtain in providing our services to you. Such information may include documenting your symptoms, test results, treatment, diagnoses, and future care or treatment plans.

We are required to abide by the terms of this Notice of Privacy Practices. If for any reason we revise our notice, we will provide you with a copy of such notice upon request.

There are many ways in which we might use your protected health information:

Treatment Purposes

• We may need to consult with one or more specialist physicians or other healthcare providers during the course of your treatment.
• Members of the office staff will document treatment information in your health record.

Payment Purposes

• Obtaining insurance approval for a procedure may require that we disclose your health information to your insurance company.
• We may disclose your protected health information to your insurance company in order to receive payment. By signing this form, you give us permission to submit claims on your behalf and receive payments from your insurance company.
• We may disclose your protected health information to Business Associates such as an electronic billing company or a collection agency.

Healthcare Operations

• We may disclose your health information to remind you of an appointment.
• Insurance companies may conduct chart audits on occasion. We may disclosure health information in this case.

Your Health Information Rights

• The electronic medical chart we maintain is the property of the Family Doctor's Office. You do have the right to:
• Request that you be allowed to inspect and receive a copy of your medical records. You must request this in writing using a form that we provide.
• Obtain a listing of disclosures we have made by requesting this in writing using a form to provide to you.
• Obtain a copy of the Notice of Privacy Practices by making a request to our office.
• Request that you be allowed to inspect your medical record and billing record upon written notice to our office on a form that we provide to you.
• Appeal a denial of access to your health information.
• Request your healthcare record be amended to correct and complete information. Information in your healthcare record may not be changed or deleted, but additional information can be added to clarify or complete the record. This needs to be requested by written notice on a form that we provide you.

Our Responsibilities

• Maintain the privacy of your health information, as required by law.
• Provide you with the Notice of Privacy Practices.
• Notify you if we cannot accommodate a request.
• Accommodate your reasonable requests regarding your healthcare information.

Other Disclosures and Uses

We may use or disclose your protected health information and the following situations without your consent:

• Workers Compensation - we may disclose your health information to comply with Workers Compensation laws.
• Law enforcement - we may disclose your health information for law enforcement purposes.
• Coroners, funeral directors - we may disclose your health information to a coroner or medical examiner for identification purposes.
• Dangerous health situations - we may disclose your health information to authorities as allowed or required by law to report abuse, neglect, certain contagious diseases, and when we feel that serious threats to your or another person’s health are present.
• Legal proceedings - we may disclose your health information in the course of any judicial proceedings, as allowed by law.
• Food and drug administration - we may disclose your health information relating to adverse advance with regards to food, products, and recalls.
• Other uses and disclosures besides those identified in this notice will be made only as otherwise authorized by law or with your written authorization.

Disclosing your Information to You

May we call you about your test results? Yes____ No____ If yes, what phone number(s) should we use? ______________________________________

May we leave an answering machine or voice mail message about your test results?
Yes____ No ____ If yes, with whom may we discuss your test results besides with yourself?
___________________________________________________________________________

May we send you test results by E-mail? Yes ____ No ____ If yes, ask for a separate E-mail Form.

May we send your test results by mail? Yes ____ No ____ If yes, what mailing address should we use? ______________________________________

Complaints

If you believe your privacy rights have been violated, you may file a complaint with the Secretary of Health and Human Services. We cannot and will not retaliate against you for filing such a claim.

If you have any questions, would like additional information, or need to report a problem with the handling of your health information, you may contact Toni Willett, Office Manager, at 816-415-2999. If you understand and agree with the practices described in this notice, please sign and date below. If there are particular parts of this notice that you did not agree with, you might cross them out prior to signing this. If the Family Doctor's Office agrees to your changes, we will abide by them. This authorization does not expire unless you revoke it in writing on a form we provide to you.

Signed: ____________________________________ Date: ______________________
Relationship to patient (i. e., parent, guardian etc.) ________________________________

The Family Doctor's Office, PC. This notice was published and becomes effective on May 24, 2004.