This notice describes how your health information may be used and disclosed and how you can access this information. PLEASE REVIEW IT CAREFULLY. We have always kept your health information secure and confidential. The HIPAA Law requires us to continue to maintain your privacy, to give you this notice and to follow the terms of this notice.
The law permits us to use or disclose your health information to those involved in your treatment.
For Example: a review of your file by a specialist physician whom we may involve in your care.
We may use or disclose your health information for payment of your services.
For Example: We may send a report of your progress to your insurance company.
We may use or disclose your health information for our normal healthcare operations.
For Example: One of our staff members will enter your information into our computer.
We may use your medical information with our business associates, such as a billing service. We will have a written contract with each business associate that requires them to protect your privacy.
We may use your information to contact you.
For Example: We may send newsletters or other information or call you to remind you of your appointment. If you are not at home, we may leave this information on your answering machine or with the person who answers the telephone.
In an emergency, we may disclose your health information to a family member or another person who is responsible for your care.
We may release some or all of your health information to a family member or another person who is responsible for your care.
Please list the name or names of persons who your health information can/may be shared with:
We may release some or all of your health information when required by law.
Except as described above, this practice will not use or disclose your health information without your prior written authorization.
You may request in writing that we not use or disclose your health information as described above. We will let you know if we can fulfill your request.
You have the right to know of any uses or disclosures we make with your health information beyond the above normal uses.
As we need to contact you from time to time, we will use whatever address or telephone number you prefer.
You have the right to request an amendment or change to your health information. If you wish to include a statement in your file, please give your request in writing. If we agree to an amendment or change, we will not remove or alter documents but we will add the new information.
You have a right to this notice. If we change any of the details of this notice, we will notify you of the changes in writing.
You may file a complaint with the Department of Health and Human Services, 200 Independence Avenue S.W., Room 509F, Washington, D.C. 20201. You will not be retaliated against for filing a complaint. However, before filing a complaint or for more information or assistance regarding your health information privacy, please contact our office (410) 559-9484. This notice goes in effect September 8, 2005.
I have received a copy of the Sarah A. Mess, MD, LLC Notice of Privacy Practices.
Signed:____________________________________________________
Date:
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Dr. Sarah Mess has either authored or reviewed and approved this content. Page Updated
