Notice of Privacy Practices
Initial Date: April 14, 2003
Revised Date: June 1, 2020
Effective Date: September 1, 2020

This Notice of Privacy Practices is required by the Privacy Regulations created as a result of the Health Insurance Portability and Accountability Act (HIPAA) of 1996. The last update and revision was August 2013 to comply with HIPAA mandates as outlined in the Omnibus Rules.

This Notice of Privacy Practices (NPP) is not an authorization. The NPP describes how protected health information (PHI) about you, as our patient, may be used and disclosed by us, our business associates, and their subcontractors, in our course of work and efforts to safely provide treatment, recoup payment for services rendered and conduct operations required or recommended to evaluate and benchmark our delivery of health care with industry standards of care. The NPP explains uses and disclosures required of us by law and how you may obtain access to your individually identifiable PHI.

Please review this notice carefully. If you have any questions about this Notice of Privacy Practices (NPP) please speak to the receptionists at the front desk or call our office at any time. We will connect you with someone in compliance to assist you with any questions or concerns. Please inquire if written notification is required to consent or opt out of any areas of the NPP as we may have forms to assist you with request and change of information processes. The content and information covered in our Notice of Privacy Practices (NPP) is divided into the following areas for your review:

A. General information about the Notice of Privacy Practices (NPP).
B. How we may use and disclose your protected health information (PHI).
C. Uses and disclosures of protected health information (PHI) required by law and other special circumstances.
D. Your individual rights.

A. General information about the Notice of Privacy Practices (NPP).

1. To whom does this notice apply and what is our pledge regarding your medical information? We understand that medical information about you and your health is personal. We are committed to protecting all medical information about you. We create a record of the care and services you receive at our practice. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to everyone who works for our practice including employees, business associate contractors, their subcontractors and volunteers. If a compromise or breach occurs related to PHI we may need to contact you by phone or by mail to make you aware of the situation.
2. Why do we publish the NPP? As medical professionals, we understand that information about you and your health is sensitive and personal. We are also required by law to maintain the privacy of information we gather and use about our patients and provide them with notices of our legal duties and privacy practices with respect to their information. We are committed to the privacy of our patients’ information; however, in order to serve them we need to gather, keep and use records of this information. We sometimes need to share information with other parties. This NPP is intended to let you know how we may use and disclose your information. The NPP also informs you of the legal rights you have with respect to the information we hold about you. You have certain rights to review and copy our records of information about you. You may also request that we amend these records and may ask us to account for certain disclosures we may have made of information about you. Our practice is required to retain and maintain records of the care given to you.
3. When is this Notice Effective? We are required to comply with the terms of this NPP while it is in effect. We reserve the right to change the terms of this NPP and make the new terms effective for all information to which this NPP applies. This NPP will be in effect immediately until the date we publish an amended NPP. If we do publish an amended NPP, we will notify you in at least one of the following ways: by sending you a copy at your last address shown in our records; by publishing the amended NPP in our offices; and/or by publishing it on our web site if we maintain one. You may request a copy of our most current NPP at any time.
4. Why might we ask you to sign other various patient consent forms in addition to acknowledgment of the NPP? We can only use or disclose information about you in very limited ways without your consent. However, we cannot provide treatment and cannot conduct payment and certain necessary health care operations activities without using or in some cases disclosing your information. Since these are essential activities for us, we need you to provide your written consent for these purposes. Because this is such important information, if you refuse to consent, we may not be able to provide you care.

B. How we may use and disclose your protected health information (PHI). Under the law, we may use or disclose your protected health information under certain circumstances without your permission. Disclosures of protected health information for treatment, payment, and health care operations (TPO, as described below) may be made without your permission. For each category, we will explain what we mean and give some examples. Not every use or disclosure within a category can or will be listed. However, most of the ways we are permitted to use and disclose health information will fall within one of the categories. Any categories listed that may require consent to allow us to use and disclose information may be revoked 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.

Below are examples of uses and disclosures of protected health information for treatment, payment, and health care operations as well as other categories.

1. Treatment - We may use and disclose medical information about you to provide you with medical treatment or services. We may disclose medical information about you to other doctors, nurses, technicians, or medical students who are involved in taking care of you in our practice. Departments/entities internal or external to our practice may also need your medical information in order to coordinate different treatments you need such as prescriptions, lab work, and diagnostic images. For example, your doctor treating you for a broken leg may need to know if you have diabetes because diabetes may slow the healing process. We may need to call or contact you to remind you about appointments or to discuss and provide you with information related to your medical conditions.
2. Payment - We may use and disclose medical information about you so that the treatment and services you receive at our practice may be billed to and payment may be collected from you, an insurance company, or a third party. For example, we may need to give your health plan information about your care received so your health plan will pay us or reimburse you for treatments provided to help keep you healthy. We may also tell your health plan about treatments you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment.
3. Health Care Operations - We may use and disclose information about you for operational functions in connection with our practice. Examples of some activities might include activities involving quality improvement, audits of our management practices, training of students involved in health care, insurance services, accounting, risk management, medical legal reviews, health plan medical quality reviews, and/or other business planning or administration needs for our practice.
4. Marketing – We may not use or disclose your PHI for marketing purposes unless you agree and consent to provide written authorization to have your information to be sold, used or disclosed for this purpose. Communications face-to-face with you to communicate information about marketed products such as prescribed drugs or refill reminders are permitted with promotional gifts at a nominal value. We may contact you regarding fundraising events and activities but you make opt out of receiving fundraising communications.
5. Fundraising – We may contact you for fundraising; however, you may, if desired, opt out after receiving initial fundraiser information. If PHI is to be used or disclosed for fundraising communications we will inform you first for authorization and provide you with an opportunity to opt out of receiving fundraising communications.
6. Psychotherapy Notes – We may not use or disclose most psychotherapy notes unless you agree and consent to provide written authorization to release this information.
7. Genetic Information – We may not use or disclose any PHI that contains genetic information unless you agree and consent to provide written authorization to have your information released. Genetic information may not be used for underwriting purposes.
8. Appointment Reminders – (OPTIONAL) Unless you object, our practice may use and disclose your information to contact you and remind you of an appointment. For example, we may mail you a postcard or call you on the phone to remind you of an appointment scheduled with our practice.
9. Treatment Options and Health – Related Benefits - (OPTIONAL) Unless you object, our practice may use and disclose information about you to inform you of potential medical options or alternative treatments or other health-related benefits and services that may improve the health and quality of your life. For example, we may mail you information about a new medication option or physical therapy modality to help provide additional relief for joint pain.
10. Release of Information to Family and Friends – (OPTIONAL) We may, unless you object, using our best discernment, disclose information to a family member, other relatives, close personal friends or any other person you identify having relevant involvement in your care or payment related to your care. For example, we may acknowledge to a spouse that you are in our office for an appointment, or we may disclose information to a relative who is involved in helping you make decisions about a surgical procedure.
11. Disclosures by Required by Law – Our practice will use and disclose your information when we are required to do so by Federal, State or Local Law.

C. Uses and disclosures of protected health information (PHI) required by law and other special circumstances.
We are legally required to use or disclose protected health information about you without your consent to meet special reporting requirements, to facilitate continuity of care, or for public health and other purposes. Some examples include:

1. Public Health Risks – We may disclose protected health information about you for public health activities. These activities generally include the following:
   • To prevent or control disease, injury or disability.
   • To report births and deaths.
   • To report child abuse or neglect.
   • To report reactions to medications or problems with products.
   • To notify people of recalls on the products they may be using.
   • To notify a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. 2 MVHIMS Revised/Updated 06/20
   • To notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect or domestic violence. We will only disclose this if you agree or when required by law.
2. Law Enforcement – Under applicable Federal and State laws, we may disclose your protected health information if we believe that its use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We may also disclose your protected health information if it is necessary for law enforcement authorities to identify or apprehend an individual.
3. Military and Veterans – We may release protected health information about you as required by military command authorities for activities believed necessary to determine fitness for duty, eligibility for VA benefits, or to a foreign military authority if you are a member of that foreign military service.
4. National Security – We may disclose your protected health information to authorized Federal officials for conducting national security and intelligence activities including protective services to the President or other officials or foreign heads of state, or to conduct special investigations.
5. Workers’ Compensation – We may release protected health information about you for workers’ compensation or similar programs. These programs provide benefits for work-related injuries or illnesses.
6. Health Oversight – We may disclose your protected health information to a health oversight agency for activities authorized by law, such as audits, investigations, inspections, and licensure. These health oversight agencies might include government agencies that oversee the health care system, government benefit programs, other government regulatory programs and civil rights laws.
7. Lawsuits and Disputes – If you are involved in a lawsuit or a dispute, we may disclose protected health information about you in response to a court order or administrative order. We may also disclose protected health information about you in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.
8. Inmates – If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release medical information about you to the correctional institution or law enforcement official. This release would be necessary: (1) for the institution to provide you with health care; (2) to protect your health and safety; (3) for the safety and security of the correctional institution.
9. Coroners, Medical Examiners and Funeral Directors – We may release protected health information to a coroner or medical examiner, to identify a deceased person or determine the cause of death. If necessary, we may also release protected health information in order for funeral directors to carry out their duties.
10. Organ and Tissue Donation – If you are an organ donor, we may release your protected health information to organizations that handle organ, eye or tissue procurement or transplantation, including organ banks, as necessary to facilitate organ or tissue donation and transplantation.
11. Research – We may disclose your protected health information to researchers when authorized by law or, for example, if their research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information. 3 MVHIMS Revised/Updated 06/20

D. Your individual rights.

1. Right to Request Confidential Communications – You may request that we communicate with you using alternative means or at an alternative location. We will not ask you the reason for your request. In order to request a specific type of communication, regarding the method and/or location you wish to be contacted, you must provide a written request to our practice. We will accommodate reasonable requests, when possible.
2. Right to Request Restrictions – You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, payment and health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, such as family members or friends. We are not required to agree to your request; however, if we do agree, we are bound by our agreement except when otherwise required by law, in emergencies, or when the information is necessary to treat and care for you. In order to request a restriction in our use or disclosure of your protected health information, you must provide a written request to our practice. Your physician is not required to agree to your requested restriction and if this happens the practice will notify you. Your physician and the practice will abide by a request to restrict and not disclose portions of your PHI to your health plan with respect to health care services for which you have paid in full and out of pocket. Your request must describe in a clear and concise fashion: (1) the information you wish to restrict, (2) whether you are requesting to limit our practice’s use, disclosure or both, and (3) to whom you want the limits to apply.
3. Right to Record Inspection and Copies – You have the right to inspect and obtain a copy of the protected health information that may be used to make decisions about you. (Please note: fees may apply.) This includes your medical records and billing records in electronic or paper format. To obtain a copy or to inspect your PHI, you must submit a request in writing to our practice. Our practice may charge a fee for the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect and/or copy in certain limited circumstances; however, if this occurs, you may request a review of our denial. Another licensed health care professional chosen by the practice will review your request and the denial. The person conducting the review will not be the person who denied your initial request. We will inform you of the outcome. Under federal law your rights to record inspection and copies does not include the following: psychotherapy notes, information compiled in reasonable anticipation of, or used in a civil, criminal, or administrative action or proceeding, PHI restricted by law, information that may be related to research in which you have agreed to participate, information whose disclosure may result in harm or injury to you or another person, or information that was obtained under a promise of confidentiality.
4. Right to Amendments – You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may request an amendment for as long as the information is kept by or for our practice. To request an amendment, your request must be made in writing to our practice. You must provide us with a reason that supports your request for the amendment. We may deny your request for an amendment if it is not in writing or does not include a reason to support the request. In addition, we may deny your request if you ask us to amend information that: (1) was not created by us, unless the person or entity that created the information is no longer available to make the amendment, (2) is not part of the medical information kept by this practice, (3) is not part of the information which you would be permitted to inspect and copy, and (4) is accurate and complete PHI.
5. Right to Accounting of Disclosures – You have a right to request an “accounting of disclosures” in paper or electronic format, except for disclosures pursuant to an authorization, 4 MVHIMS Revised/Updated 06/20 for purposes of treatment, payment and operations, required by law, that occurred prior to April 14, 2003 or six years prior to the date of the request. This is a list of certain non-routine disclosures we made of the medical information about you. The accounting of disclosures does not require us to list for example a doctor sharing information with the nurse, another doctor or the billing department. All requests for an accounting of disclosures must be made in writing to our practice. Attached at the end of this NPP is the person and information to whom written requests are to be addressed. The request must state a time period, which may not be longer than 6 (six) years and may not include dates before April 14, 2003. The first list you request within a 12 (twelve) month period is free of charge, but our practice may charge you for additional lists within the same 12 (twelve) month period. We will notify you of the costs involved with additional requests, and you may withdraw your request before you incur any costs.
6. Right to Authorize Other Uses and Disclosures – Other uses and disclosures of medical information not covered by this NPP or the laws that apply to us will be made only with your written authorization/consent/permission. If you provide us with permission to use or disclose medical information about you, and subsequently desire to revoke that authorization, you may do so at any time in writing to our practice. If you revoke the authorization, we will no longer use or disclose medical information about you for the reasons described in your written authorization. Our practice will not be able to take back any disclosures we have already made with your permission.
7. Right to a Paper Copy of this Privacy Notice – You have the right to be provided with a paper copy of this NPP from our practice. You may ask us to give you a copy of this NPP at any time. Even if you have agreed to receive this notice electronically, you are still entitled to a paper copy.
8. Right to File a Complaint – If you believe your privacy rights have been violated, please notify our practice to help resolve the situation. To file a complaint with our practice, contact the front reception desk to be connected to someone in compliance. You may file a complaint with our practice or with the Secretary of the Department of Health and Human Services. All formal complaints must be submitted in writing. The Secretary of the Department of Health and Human Services requires that the complaint be in writing, either paper or electronically, that it names the practice involved and the acts or omissions believed to be in violation, and that this be filed within 180 days of when you knew of the omission or act occurring. You will not be penalized for filing a complaint.

Changes to This Notice of Privacy Practices

We reserve the right to change this NPP. We reserve the right to make the revised or changed NPP effective for medical information we already have about you as well as any information we receive in the future. A copy of the current NPP is available at any time in the practice and is posted in a clear and prominent location for patients to see and have an opportunity to read. The NPP is to be posted on a Web Site if the practice maintains one. We are required to obtain acknowledgement of your review to read the NPP or receipt of a copy of the NPP. The NPP will contain the effective date on the first page under the title Notice of Privacy Practices.