NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
THE PRIVACY OF YOUR PROTECTED HEALTH INFORMATION IS IMPORTANT TO US.
Our Legal Duty
We are required by applicable federal and state law to maintain the privacy of your protected health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect January 1, 2013 and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all protected health information that we maintain, including protected health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and provide the new Notice at our practice location, and we will distribute it upon request.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this notice.
Your Authorization: In addition to our use of your protected health information for the following purposes, you may give us written authorization to use your protected health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your protected health information for any reason except those described in this Notice.
Uses and Disclosures of Protected Health Information
We use and disclose protected health information about you without authorization for the following purposes.
Treatment: We may use or disclose your protected health information for your treatment. For example, we may disclose your protected health information to a physician or other healthcare provider providing treatment to you.
Payment: We may use and disclose your protected health information to obtain payment for services we provide to you. For example, we may send claims to your health plan containing certain protected health information.
Healthcare Operations: We may use and disclose your protected health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
To You Or Your Personal Representative: We must disclose your protected health information to you, as described in the Patient Rights section of this Notice. We may disclose your protected health information to your personal representative, but only if you agree that we may do so.
Persons Involved In Care: We may use or disclose protected health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your protected health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your absence or incapacity or in emergency circumstances, we will disclose protected health information based on a determination using our professional judgment disclosing only protected health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of protected health information.
Sign in Sheet: We may use and disclose medical information about you by having you sign in when you arrive at our office. The sign in sheet will contain only minimal information. We may also call out your name when we are ready to see you.
Disaster Relief: We may use or disclose your protected health information to assist in disaster relief efforts.
Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization. The Privacy Rule does, however, permit the use of marketing that is in the form of a face-to-face communication or a promotional gift of nominal value.
Research: We may release certain information for research purposes, as approved by an Institutional Review Board or privacy board, in compliance with governing law.
To Avert Serious Threat to Health or Safety: We may, and are sometimes required by law, to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or the general public.
Psychotherapy Notes: Unless otherwise expressly permitted by the Privacy Rule, psychotherapy notes cannot be disclosed without your written authorization. Our practice does not maintain psychotherapy notes.
Sale of Protected Health Information: Unless we obtain your written authorization, we cannot sell your protected health information.
Required by Law: We may use or disclose your protected health information when we are required to do so by law.
Public Health and Public Benefit: We may use or disclose your protected health information to report abuse, neglect, or domestic violence; to report disease, injury, and vital statistics; to report certain information to the Food and Drug Administration (FDA); to alert someone who may be at risk of contracting or spreading a disease; for health oversight activities; for certain judicial and administrative proceedings; for certain law enforcement purposes; to avert a serious threat to health or safety; to report vaccine administration to schools; and to comply with workers’ compensation or similar programs.
Decedents: We may disclose protected health information about a decedent as authorized or required by law. We may disclose protected health information about a decedent for cadaveric organ, eye or tissue donation purposes. Protected health information does not include health information about individuals who have been deceased for more than 50 years.
National Security: We may disclose to military authorities the protected health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials protected health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody the protected health information of an inmate or patient under certain circumstances.
Appointment Reminders: We may use or disclose your protected health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).
Access: You have the right to look at or get copies of your protected health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your protected health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice. We will charge you a reasonable cost-based fee for the cost of supplies and labor of copying. If you request copies, we will charge you $0.65 for each page of a paper copy or $0.45 for an electronic copy, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your protected health information in that format. Additional fees may apply for copies of x-ray files. If you prefer, we will prepare a summary or an explanation of your protected health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your protected health information for purposes other than treatment, payment, healthcare operations, and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your protected health information. In most cases we are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in certain circumstances where disclosure is required or permitted, such as an emergency, for public health activities, or when disclosure is required by law). We must comply with a request to restrict the disclosure of protected health information to a health plan for purposes of carrying out payment or health care operations (as defined by HIPAA) if the protected health information pertains solely to a health care item or service for which we have been paid out of pocket in full. We must agree to a restriction where you, or someone on behalf of you, has paid out of pocket in full for a service.
Alternative Communication: You have the right to request that we communicate with you about your protected health information by alternative means or at alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request. We will accommodate reasonable requests.
Amendment: You have the right to request that we amend your protected health information. Your request must be in writing, and it must explain why the information should be amended. We are not required to change your health information may deny your request under certain circumstances, and in which case, we will explain the basis for the denial and how you can dispute the denial.
Electronic Notice: You may receive a paper copy of this notice upon request, even if you have agreed to receive this notice electronically on our Web site or by electronic mail (e-mail).
Breach: We are obligated by law to notify you following a breach of your protected health information by us or one of our business associates. We do not anticipate any breach of your protected health information but you shall receive information explaining the breach in any notification you receive from us.
Special Rules Regarding Disclosure of Psychiatric, Substance Abuse and HIV Related Information: Under Connecticut or federal law, additional restrictions may apply to disclosures of health information that relates to care for psychiatric conditions, substance abuse or HIV-related testing and treatment. This information may not be disclosed without your specific written permission, except as may be specifically required or permitted by Connecticut or federal law. The following are examples of disclosures that may be made without your specific written permission:
- Psychiatric information. We may disclose psychiatric information to a mental health program if needed for your diagnosis or treatment. We may also disclose very limited psychiatric information for payment purposes.
- HIV-related information. We may disclose HIV-related information for purposes of treatment or payment.
- Substance abuse treatment. We may disclose information obtained from a substance abuse program in an emergency.
Questions and Complaints
If you want more information about our privacy practices or have questions or concerns, please contact us.
If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your protected health information or in response to a request you made to amend or restrict the use or disclosure of your protected health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.
We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
Contact Officer: Eleanor Predom
E-mail: [email protected]
Address: 31 Broadway, North Haven, CT 06473