Treating the Toughest Cases of Depression and Brain Illness

HIPAA 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 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 related health care services.

Uses and Disclosures of 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 reuse required by law.

Treatment: We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes the coordination of management of your health care with a third party. 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 and treat you.

Healthcare Operations: We may use or disclose, as needed, your PHI in order to support the business activities of the physician’s practices. 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.
  • We may call you by name in the waiting room when the physician is ready to see you.
  • We may use/disclose your PHI, as necessary, to contact you for appointment reminders.
  • We may use/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: 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: Worker’s Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164,500.

The following is a statement of your rights with respect to your 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 the protected health information.

You have the right to request a restriction of your PHI:
Disclose any part of your PHI for the purposes of treatment, payment or healthcare operations. You may also request that nay part of your PHI 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 your physician believes it is in your best interest to permit use and disclosure of your PHI, your 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 ie, electronically.

You have the right to have your physician amend your PHI:
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 any such rebuttal.

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 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 to the Secretary of Health and Human Service if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying your privacy contact of your complaint. We will not retaliate against you for filing a complaint. We are required by law to maintain the privacy of, and provide individuals with, this notice of your legal duties and privacy practices with respect to PHI. If you have any objections to this form, please speak with our Medical Director in person or by phone.

Notice of Privacy Practices
We at TNC are required by law to maintain the privacy of and provide individuals with the attached notice of our legal duties and privacy practices with respect to PHI. If you have any objections to the Notice, please ask to speak with our Medical Director in person or by phone. If you would like a copy of the Notice, please ask. 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, expect 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.

I hereby acknowledge that I have reviewed the HIPAA Notice of Privacy Practice document.

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