medical information for research, the project will have been approved through this research approval process, but we may, however, disclose medical information about you to people preparing to conduct a research project, for example, to help them look for patients withspecific medical needs. We will almost always ask for your specific permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in your care in our practice. As Required By Law: We will disclose protected medical information about you when required to do so by federal, state or local law. local la To Avert a Serious Threat to Health or Safety: We may use and disclose protected medical information about you when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat. SPECIAL SITUATIONS Organ and Tissue Donation: If you are an organ donor, we may release protected medical information to organizations that handle organ procurement or organ, eye or tissue transplantation or to an organ donation bank, as necessary to facilitate organ or tissue donation and transplantation. Military and Veterans: If you are a member of the armed forces, we may release protected medical information about you as required by military command authorities. We may also release protected medical information to a foreign military authority, if you are in their service. Workers' Compensation: We may release protected medical information about you for workers' compensation or similar programs. These programs provide benefits for work related injuries or illness. Release of such information is controlled by state and/or federal law. Public Health Risks: We may disclose protected medi Public Health Risks: cal 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 a known or suspected crime, • to report child abuse or neglect; • to report vulnerable adult abuse; • to report reactions to medications or problems with products; • to • 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; • to notify the appropriate government authority if we believe a patient has been the victim of domestic violence. We will only make this disclosure if you agree or when required or authorized by law. Health Oversight Activities: We may disclose protected medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to moni activities a tor the health care system, government programs, and compliance with civil rights laws. Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose protected medical 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. Law Enforcement: We may release protected medical information if asked to do so by a law enforcement official: • in response to a court order, subpoena, warrant, summons or similar process; • to identify or locate a suspect, fugitive, material witness, or missing person; • to identify or locate a suspect, fugitive, material witness, or missing person; • about the victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement; • about a death we believe may be the result of criminal conduct; • about criminal conduct involving our practice; and • in emergency circumstances to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime. Privacy Practices Notice Page 3 Medical Examiners and Funeral Directors: We may release protected medical information to a medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also release protected medical information about patients to funeral directors as necessary to carry out their duties. National Security and Intelligence Activities: We may release protected medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law. Protective Services for the President and Others: We may disclose protected info for the rmation about you to authorized federal officials so they may provide protection to the President, other authorized persons or foreign heads of state or conduct special investigations. YOUR RIGHTS REGARDING MEDICAL INFORMATION ABOUT YOU You have the following rights regarding protected medical information we maintain about you: Right to Inspect and Copy: You have the right to inspect and copy medical information that may be used to make decisions about your care. This includes medical and billing records, but does not include psychotherapy notes. To inspect and/or copy your medical information you must submit your request to our privacy notice. If you request a c copy opy of the information, we may charge a fee for the costs of copying, mailing or other supplies associated with your request. (By statute we may charge you $ 0 . 2 5 per page for copies, plus our postage costs. If your record contains any item that requires a photographic process to copy, such as an x-ray or photograph, we may charge you up to $5.00 per image.) Right to Amend: If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by our practice. To request an amendment, your request must be made T in writing and submitted to our Privacy Officer. In addition, you must provide a reason that supports your amendment request. 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: • was not created by us, unless the person or entity that created the information is no longer available to make the amendment; • is not part of the medical information kept by our practice; • is not part of the information which you would be permitted to inspect and copy; or • in our judgment is accurate and complete as it appears or as it was at the time it was originally captured and recorded. Right to an Accounting of Disclosures: You have the right to request an "accounting of disclosures." This is a list of the disclosures we have made of your medical information. To request this list or accounting of disclosures, you must submit your request in writing to our Privacy Officer. Your request must state a time period which may not be longer than six years and may not include dates before April 14, 2003. The first list you request within each 12 month period will be fre you e. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time, before any costs are incurred. Right to Request Restrictions: You have the right to request a restriction or limitation on the protected medical information we use or disclose about you for treatment, payment or health care operations. However, we must receive your restrictions in writing before we have made such disclosures. Also, if you restrict our right to use your protected medical information for treatment, payment or health operations, we reserve t the right to immediately withdraw our services form you and terminate the physician-patient relationship. You also have the right to request a limit on the protected medical information we disclose about you to someone who is involved in your care or the payment for your care, such as a family member or friend. For example, you could ask that we not use or disclose information about a surgery to your family. We are not required to agree to your request. If we do agree, we will comply with your request unless the information is needed to provide you emergency treatment. To request restrictions, you must make your request in writing to T our Privacy Officer. In your request restrictions, you must tell us (1) what information you want to limit;(2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply, for example, disclosures to your spouse. Privacy Practices Notice _______________________________________________ _____________________________ Patient Signature Date Page 4 Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work, or at home, or by mail, or by phone, or by E-mail. To request confidential communications, you must make your request in writing to our Privacy Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. Right to a Copy of This Notice: You have the right Right to a Copy of This Notice: to a copy of this notice. You may ask us to give you a copy of this notice at any time. CHANGES TO THIS NOTICE We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for protected medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our office. The notice will contain on the first page, in the top right hand corner, the effective date. In addition, each time you are in our office for treatment or health care services, we will offer you a copy of the current notice in effect. notice in e COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact our Privacy Officer at 706-322-4073. All complaints must be submitted in writing. If you wish to file a complaint with the Secretary of the Department of Health and Human Services, contact Office of Civil Rights, Region VI, U.S. Department of Health and Human Services, 1301 Young Street, Suite 1169, Dallas, TX 75202, Phone (214) 767-4056, Fax (214) 767-0432, TDD (214) 767-8940, Email OCRComplaint@hhs.gov. You will not be penalized for filing a complaint. OCRComplaint@hhs.go OTHER USES OF MEDICAL INFORMATION Other uses and disclosures of protected medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose protected medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose protected medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are r a equired to retain our records of the care that we provided to you. Privacy Practices Notice Right to Request Confidential Communications: You have the right to request that we communicate with you about medical matters in a certain way or at a certain location. For example, you can ask that we only contact you at work, or at home, or by mail, or by phone, or by E-mail. To request confidential communications, you must make your request in writing to our Privacy Officer. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted. Right to a Copy of This Notice: You have the right to a copy of this notice. You may ask us to give you a copy of this notice at any time. CHANGES TO THIS NOTICE We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for protected medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in our office. The notice will contain on the first page, in the top right hand corner, the effective date. In addition, each time you are in our office for treatment or health care services, we will offer you a copy of the current notice in effect. COMPLAINTS If you believe your privacy rights have been violated, you may file a complaint with our office or with the Secretary of the Department of Health and Human Services. To file a complaint with our office, contact our Privacy Officer at 706-322-4073. All complaints must be submitted in writing. If you wish to file a complaint with the Secretary of the Department of Health and Human Services, contact Office of Civil Rights, Region VI, U.S. Department of Health and Human Services, 1301 Young Street, Suite 1169, Dallas, TX 75202, Phone (214) 767-4056, Fax (214) 767-0432, TDD (214) 767-8940, Email OCRComplaint@hhs.gov. You will not be penalized for filing a complaint. OTHER USES OF MEDICAL INFORMATION Other uses and disclosures of protected medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose protected medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose protected medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you. Please provide Patient Authorization & Acknowledgement or Patient Consent Authorization.