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Notice of Privacy
Practices
Effective Date: April 3, 2003
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.
We understand the importance of privacy, and are committed to
maintaining the confidentiality of your medical information. We make a
record of the medical care we provide, and may receive such records from
others. We use these records to provide or enable other health care
providers to provide quality medical care, to obtain payment for
services provided to you as allowed by your health plan and to enable us
to meet our professional and legal obligations to operate this medical
practice properly. We are required by law to maintain the privacy of
protected health information and to provide individuals with notice of
our legal duties and privacy practices with respect to protected health
information. This notice describes how we may use and disclose your
medical information. It also describes your rights and our legal
obligations with respect to your medical information. If you have any
questions about this Notice, please contact our Privacy Officer listed
above.
How this Medical Practice May Use or Disclose Your Health Information
The law permits us to use or disclose your health information for the
following purposes:
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Treatment. We may use medical information about you to
provide your medical care. We disclose medical information to our
employees and others who are involved in providing the care you need.
For example, we may share your medical information with other physicians
or other health care providers who will provide services, which we do
not provide. We may also share this information with a pharmacist who
needs it to dispense a prescription to you, or a laboratory that
performs a test.
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Payment. We may use and disclose medical information about
you to obtain payment for the services we provide. For example, we may
give your health plan the information it requires before it will pay us.
We may also disclose information to other health care providers to
assist them in obtaining payment for services they have provided to you.
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Health Care Operations. We may use and disclose medical
information about you to operate this medical practice. For example, we
may use and disclose this information to review and improve the quality
of care we provide, or the competence and qualifications of our
professional staff. We may also use and disclose this information to
request that your health plan authorize services or referrals. We may
also use and disclose this information as necessary for medical reviews,
legal services and audits, including fraud and abuse detection and
compliance programs and business planning and management. We may also
share your information with other health care providers, a health care
clearinghouse or health plans that have a relationship with you when
they request this information, to help them with their quality
assessment and improvement activities, their efforts to improve health
or reduce health care costs, their review of compliance, qualifications
and performance of health care professionals, their training programs,
their accreditation, certification or licensing activities, or their
health care fraud and abuse detection and compliance efforts.
[Participants in organized health care arrangements only should add: We
may also share medical information about you to all the other health
care providers [health care clearinghouses] [and health plans] who
participate in [name of organized health care arrangement] for any
health care operations activities of [name of organized health care
arrangement.]
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Business Associates. We may share your medical information
with our "business associates", such as our billing service
that performs administrative services for us. We have a written contract
with each of these business associates that contains terms requiring
them to protect the confidentiality of your medical information.
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Appointment Reminders. We may use and disclose medical
information to contact and remind you about appointments. If you are not
home, we may leave this information with the person answering the phone
or on your answering machine.
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Sign in sheet. We may ask you to sign in when you arrive at
our office. We may also call out your name when we are ready to see you.
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Notification and communication with family. We may disclose
your health information to a family member or a close friend or other
person you identify where relevant to that person's involvement in your
care or payment for your care. We may disclose your health information
to notify or assist in notifying a family member, your personal
representative or another person responsible for your care about your
location, your general condition or in the event of your death. In the
event of a disaster, we may disclose information to a relief
organization so that they may coordinate these notification efforts. If
you are able and available to agree or object, we will give you the
opportunity to object prior to making these disclosures, although we may
disclose this information in a disaster even over your objection if we
believe it is necessary to respond to the emergency circumstances. If
you are unable or unavailable to agree or object, our health
professionals will use their best judgment in communicating with your
family and others.
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Marketing. We may contact you to give you information about
product or services related to your treatment, case management or care
coordination, or to direct or recommend other treatments or
health-related benefits and services that may be of interest to you. We
may also encourage you to purchase a product or service when we see you.
We will not use of disclose your medical information for marketing
purposes without your written authorization.
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Required by law. As required by law, we will use and
disclose your health information, but we will limit our use or
disclosure to the relevant requirements of the law. When the law
requires us to report abuse, neglect or domestic violence, or respond to
judicial or administrative proceedings, or to law enforcement officials,
we will further comply with the requirement set forth below concerning
those activities.
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Public health. We may, and are sometimes required by law
to disclose your health information to public health authorities for
purposes related to: preventing or controlling disease, injury or
disability; reporting child, elder or dependent adult abuse or neglect;
reporting domestic violence; reporting to the Food and Drug
Administration problems with products and reactions to medications; and
reporting disease or infection exposure. When we report suspected elder
or dependent adult abuse or domestic violence, we will inform you or
your personal representative promptly unless in our best professional
judgment, we believe the notification would place you at risk of serious
harm or would require informing a personal representative we believe is
responsible for the abuse or harm.
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Health oversight activities. We may, and are sometimes
required by law to disclose your health information to health oversight
agencies during the course of audits, investigations, inspections,
licensure and other proceedings.
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Judicial and administrative proceedings. We may, and are
sometimes required by law, to disclose your health information in the
course of any administrative or judicial proceeding to the extent
expressly authorized by a court or administrative order. We may also
disclose information about you in response to a subpoena, discovery
request or other lawful process if reasonable efforts have been made to
notify you of the request and you have not objected, or if your
objections have been resolved by a court or administrative order.
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Law enforcement. We may, and are sometimes required by
law, to disclose your health information to a law enforcement official
for purposes such as identifying of locating a suspect, fugitive,
material witness or missing person, complying with a court order,
warrant, grand jury subpoena and other law enforcement purposes.
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Coroners. We may, and are often required by law, to
disclose your health information to coroners in connection with their
investigations of deaths.
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Organ or tissue donation. We may disclose your health
information to organizations involved in procuring, banking or
transplanting organs and tissues.
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To avert a 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.
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Specialized government functions. We may disclose your
health information for military or national security purposes or to
correctional institutions or law enforcement officers that have you in
their lawful custody.
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Worker's compensation. We may disclose your health
information as necessary to comply with worker's compensation laws. For
example, to the extent your care is covered by workers' compensation, we
will make periodic reports to your employer about your condition. We are
also required by law to report cases of occupational injury or
occupational illness to the employer or workers' compensation insurer.
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Change of Ownership. In the event that this medical
practice is sold or merged with another organization, your health
information/record may be transferred the new owner, although you will
maintain the right to request that copies of your health information be
transferred to another physician or medical group.
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Research. We may disclose your health information to
researchers conducting research with respect to which your written
authorization is not required as approved by an Institutional Review
Board or privacy board, in compliance with governing law.]
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Directories. Unless you object, we will include your name,
the location at which you are receiving care, your condition (in general
terms) and your religious affiliation in our facility directory. Members
of the clergy will be told your religious affiliation. The other
information will be disclosed to people who ask for you by name.]
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When This Medical Practice May Not Use or Disclose Your Health
Information
Except as described in this Notice of Privacy Practices, this medical
practice will not use or disclose health information, which identifies
you without your written authorization. If you do authorize this medical
practice to use or disclose your health information for another purpose,
you may revoke your authorization in writing at any time, except to the
extent that we have already taken action in reliance on the
authorization.
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Your Health Information Rights
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Right to Request Special Privacy Protections. You have the
right to request restrictions on certain uses and disclosures of your
health information, by submitting a written request specifying what
information you want to limit and what limitations on our use or
disclosure of that information you wish to have imposed. We reserve the
right to accept or reject your request, and will notify you of our
decision.
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Right to Request Confidential Communications. You have the
right to request that you receive your health information in a specific
way or at a specific location. For example, you may ask that we send
information to a particular e-mail account or to your work address. We
will comply with all reasonable requests submitted in writing which
specify how or where you wish to receive these communications.
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Right to Inspect and Copy. You have the right to inspect
and copy your health information, with limited exceptions. To access
your medical information, you must submit a written request detailing
what information you want access to and whether you want to inspect it
or get a copy of it. We will charge a reasonable fee, as allowed by
Connecticut law. We may deny your request under limited circumstances.
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Right to Amend or Supplement. You have a right to request
that we amend your health information that you believe is incorrect or
incomplete. You must make a request to amend in writing, and include the
reasons you believe the information is inaccurate or incomplete. We are
not required to change your health information, and will provide you
with information about this medical practice's denial and how you can
disagree with the denial. We may deny your request if we do not have the
information, if we did not create the information (unless the person or
entity that created the information is no longer available to make the
amendment), if you would not be permitted to inspect or copy the
information at issue, or if the information is accurate and complete as
is.
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Right to an Accounting of Disclosures. You have a right to
receive an accounting of disclosures of your health information made by
this medical practice, except that this medical practice does not have
to account for the disclosures provided to you or pursuant to your
written authorization, or as described in paragraphs 1 (treatment), 2
(payment), 3 (health care operations), 7 (notification and communication
with family) and 17 (certain government functions) of Section A of this
Notice of Privacy Practices or disclosures of data which exclude direct
patient identifiers for purposes of research or public health or
disclosures which are incident to a use or disclosure otherwise
permitted or authorized by law, or the disclosures to a health oversight
agency or law enforcement official to the extent this medical practice
has received notice from that agency or official that providing this
accounting would be reasonably likely to impede their activities and
certain other disclosures.
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Right to Receive a Notice of Privacy Practices. You have a
right to receive a paper copy of this Notice of Privacy Practices, even
if you have previously requested its receipt by e-mail.
If you would like to have a more detailed explanation of these rights
or if you would like to exercise one or more of these rights, contact
our Privacy Officer listed at the top of this Notice of Privacy
Practices.
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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:
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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.
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HIV-related information. We may disclose HIV-related information for
purposes of treatment or payment.
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Substance abuse treatment. We may disclose information obtained from
a substance abuse program in an emergency.
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Changes to this Notice of Privacy Practices
We reserve the right to amend this Notice of Privacy Practices at any
time in the future. Until such amendment is made, we are required by law
to comply with this Notice. After an amendment is made, the revised
Notice of Privacy Protections will apply to all protected health
information that we maintain, regardless of when it was created or
received. We will keep a copy of the current notice posted in our
reception area, and provide you with a copy upon request. [For practices
with websites add: We will also post the current notice on our website.]
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Complaints
Complaints about this Notice of Privacy Practices or how this medical
practice handles your health information should be directed to our
Privacy Officer listed at the top of this Notice of Privacy Practices.
You may also submit a complaint to:
Department of Health and Human Services
Office of Civil Rights
Hubert H. Humphrey Bldg.
200 Independence Avenue, S.W.
Room 509F HHH Building
Washington, DC 20201
You will not be penalized for filing a complaint.
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