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 CAREFULLY.
Uses and Disclosures
Treatment. Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing medical conditions, and providing treatment. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals who may provide treatment or who may be consulted by staff members.
Payment. Your health information may be used to seek payment from your health plan, from other sources of coverage such as an automobile insurer, or from credit card companies that you may use to pay for services. For example, your health plan may request and receive information on dates of service, the services provided, and the medical condition being treated.
Health care operations. Your health information may be used as necessary to support the day-to-day activities and management of NY ORTHOPEDICS. For example, information on the services you received may be used to support budgeting and financial reporting, and activities to evaluate and promote quality.
Law enforcement. Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting.
Public health reporting Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state's public health department.
Other uses and disclosures require your authorization. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision.
Additional Uses of Information
Appointment reminders. Your health information will be used by our staff to send you appointment reminders.
Information about treatments. Your health information may be used to send you information on the treatment and management of your medical condition that you may find to be of interest. We may also send you information describing other health-related goods and service that we believe may interest you.
Fund raising. Unless you request us not to, we may use your name and address to support our fund raising efforts. If you do not want to participate in fund raising efforts, please check off the appropriate box on the acknowledgement form.
Individual Rights
You have certain rights under the federal privacy standards. These include:
- The right to request restrictions on the use and disclosure of your protected health information
- The right to receive confidential communications concerning your medical condition and treatment
- The right to inspect and copy your protected health information
- The right to amend or submit corrections to your protected health information
- The right to receive an accounting of how and to whom your protected health information has been disclosed
- The right to receive a printed copy of this notice
NY ORTHOPEDICS Duties
We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices.
We also are required to abide by the privacy policies and practices that are outlined in this notice.
Right to Revise Privacy Practices
As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Whatever the reason for these revisions, we will provide you with a revised notice on your next office visit. The revised policies and practices will be applied to all protected health information that we maintain.
Requests to Inspect
Protected Health Information
As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting the Receptionist or the Practice Administrator.
Complaints
If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns to:
Practice Administrator
NY ORTHOPEDICS
130 East 77th Street
Black Hall 5th Floor
New York, NY10075
If you believe that your privacy rights have been violated, you should call the matter to our attention by sending a letter describing the cause of your concern to the same address.
You will not be penalized or otherwise retaliated against for filing a complaint.
Contact Person
The name and address of the person you can contact for further information concerning our privacy practices is:
Practice Administrator
NY ORTHOPEDICS
130 East 77th Street
Black Hall 5th Floor
New York, 10075
212 737-3301
Effective Date
This Notice is effective on or after April 14th , 2003.
Use and Disclosure of Your
Protected Health Information
Your protected health information will be used by NY ORTHOPEDICS or disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of the practice.
Fund raising. Unless you request us not to, we may use your name and address to support Lenox Hill Hospital and NISMAT fund raising efforts. If you do not want to participate in fund raising efforts, please check off the following box. I do not wish to participate in fund raising efforts.
Notice of Privacy Practices
You should review the Notice of Privacy Practices for a more complete description of how your protected health information may be used or disclosed. You may review the notice prior to signing this consent.
Requesting a Restriction on the
Use or Disclosure of Your Information
You may request a restriction on the use or disclosure of your protected health information. NY ORTHOPEDICS may or may not agree to restrict the use or disclosure of your protected health information. If NY ORTHOPEDICS agrees to your request, the restriction will be binding on the practice. Use or disclosure of protected information in violation of an agreed upon restriction will be a violation of the federal privacy standards.
Revocation of Consent
You may revoke this consent to the use and disclosure of your protected health information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected.
Reservation of Right to
Change Privacy Practices
NY ORTHOPEDICS reserves the right to modify the privacy practices outlined in the notice.
Signature
I have reviewed this consent form and received a copy of Notice of Privacy Practices. I give my permission to NY ORTHOPEDICS to use and disclosure my health information in accordance with it.
________________________________________ _____________________________________
Name of Patient (Print or Type) Signature of Patient Representative
________________________________________ _____________________________________
Signature of Patient Relationship of Patient Representative to Patient
____________________
Date
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