PATIENT/CLIENT NOTIFICATION OF PRIVACY PRACTICES
I understand that, under the Health Insurance Portability & Accountability Act of 1996 {HIPAA}, I have certain rights to privacy regarding my protected and confidential health information. I understand that this information can and will be used to:
- Obtain Conduct, plan, and direct treatment and follow-up among the multiple healthcare providers who may be involved in treatment, either directly or indirectly.
- Payment from any third-party payers, i.e., insurance companies, etc.
- Conduct normal healthcare operations, such as quality assessments, physician referrals within and outside of our Center, and care planning.
- Communicate with you, the patient. This can include disclosing your medical information i.e. lab results to you, reminding you of upcoming appointments, reminding you of missed appointments, collecting pertinent information about your insurance or contact information, et al.
We may use and disclose medical information and you WITHOUT your specific authorization, as follows:
- Public Health Activities: We may disclose your medical information to a public agency, such as the Food and Drug Administration (FDA), if you experience an adverse effect from any of the drugs, supplies, or equipment we use.
- Judicial and Administrative Proceedings: We may have to disclose your medical information if we receive a subpoena from a judge or administrative tribunal.
- Law Enforcement: We may have to disclose your medical information in conjunction with a crime investigation by a federal or state law enforcement agency.
Patient Rights
You have certain rights with respect to your certain medical information.
- Requesting Restrictions: You may ask to limit our use or disclosure of your protected health information. We are not required to agree to your request, but if we agree to it, we will abide by your request except as required by law, in emergencies, or when the information is necessary to treat you. Your request must: 1.) be in writing, 2.) describe the information that you want restricted, 3.) state if the restriction is to limit our use or disclosure, and 4.) state to whom the restriction applies. You may revoke your restriction at any time by contacting our office. We may ask to reschedule your exam while we consider your request.
- Paper copy of This Notice: You are entitled to receive a paper copy of our PATIENT/CLIENT NOTIFICATION OF PRIVACY PRACTICES by contacting our office.
File a Complaint: If you believe that we have violated your privacy rights, you may file a complaint directly with our Office Manager. We will not penalize you for complaining. - I have read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that Christine Tymczyna DO PLLC and Partner
In Health AZ, LLC has the right to change its Notice of Privacy Practices and that I may contact the Privacy Officer at any time to obtain a current copy of such practices.
I understand that I may request in writing that you restrict how my private information is used and disclosed to carry out treatment or health care operations. If restrictions are placed, we Christine Tymczyna DO PLLC and Partner In Health AZ, LLC is not required to agree, but if agreed upon will abide by such restrictions.
I understand that I am not required to give my consent to do so and that I may revoke this authorization at any time.
