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Notice of Privacy Practices





This notice applies to the information and records we have about your health,health status, and the healthcare and services you receive at this office.  We are required by law to give you this notice.  It will tell you about the ways in which we may use and disclose health information about you and describes your rights and our obligations regarding the use and disclosure of that information. 


We may use and disclose health information about you for treatment,payment,and healthcare operations. For example:


TREATMENT:    We may use health information about you to provide you with medical treatment and services.  We may disclose health information about you to doctors, nurses, technicians, office staff or other personnel who are involved in taking care of you and your health.  This may include sharing information about you to people who do not work in our office in order to coordinate your care, such as phoning in prescriptions, scheduling lab work and procedures.  Family members and other healthcare providers may be part of your medical care outside this office and may require information about you that we have.


PAYMENT:  We may use and disclose your health information so that the treatment and services you receive at this office may be billed to and payment may be collected from you, an insurance company or a third party.  We may also tell your health plan about a treatment you are going to receive to obtain prior approval, or to determine whether you plan will cover the treatment.


HEALTHCARE OPERATIONS:  We may use and disclose your health information in order to run the office and make sure you and our other patients receive quality care.  This may include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluation practitioner and provider performance, conducting training programs, accreditation certification, licensing or credentialing activities.


APPOINTMENT REMINDERS:  We may contact you as a reminder that you have an appointment for treatment or medical care at the office or other healthcare facility.


TREATMENT ALTERNATIVES: We may tell you about or recommend possible treatment options or alternatives that may be of interest to you. 


HEALTHCARE RELATED PRODUCTS AND SERVICES:  We may tell you about health-related products or services that may be of interest to you.


Please notify us if you do not wish to be contacted for appointment reminders, or if you do not wish to receive communications about treatment alternatives or health-related products and services.  If you advise us in writing that you do not wish to receive such communications, we will not use or disclose your information for these purposes.  You may revoke your Consent at any time by giving us written notice.  Your revocation will be effective when we receive it, but it will not apply to any uses and disclosures that occured before that time.  If you do revoke your Consent, we will not be permitted to use or disclose your information for purposes of treatment, payment or healthcare operations, and we may therefore choose to discontinue providing you with healthcare treatment and services.


SPECIAL SITUATIONS:   We may use or disclose health information about you without your permission for the following purposes, subject to all applicable legal requirements and limitations:


TO AVERT A SERIOUS THREAT TO HEALTH OR SAFETY:  We may use and disclose your health information when necessary to prevent a serious threat to your health and safety or the health and safety of the public or another person.


REQUIRED BY LAW:  We will disclose your health information when required to do so by federal, state or local law.


RESEARCH:  We may use and disclose your health information for research projects that are subject to a special approval process.  We will ask you for your permission if the researcher will have access to your name, address or other information that reveals who you are, or will be involved in you care at the office.


ORGAN OR TISSUE DONATION:  If you are an organ donar, we may release health information to organizations that handle organ procurement or organ,eye or tissue transplantation or to an organ donation bank, as necessary to facilitate such donation and transplantation.


MILITARY, VETERANS, NATIONAL SECURITY AND INTELLIGENCE:  If you are or were a member of the armed forces, or part of the national security or intelligence communities, we may be required by military command or other government authorities to release your health information.  We may also release information about foreign military personnel to the appropriate foreign military authority.


WORKERS' COMPENSATION:  We may release your health information for workers' compensation or similar programs.  These programs provide benefits for work-related injuries or illness.


PUBLIC HEALTH RISKS:  We may disclose your health information for public health reasons in order to prevent or control disease, injury, or disability; or report births, deaths, suspected abuse or neglect, non-accidental physical injuries, reactions to medications or problems with products.


HEALTH OVERSIGHT ACTIVITIES:  We may disclose health information to a health oversight agency for audits, investigations, inspections, or licensing programs.  These disclosures may be necessary for certain state or federal agencies to monitor the healthcare systems, government programs, and compliance with civil rights laws.


LAWSUITS AND DISPUTES:  If you are involved in a lawsuit or dispute, we may disclose your health information in response to a court or administrative order.  Subject to all applicable legal requirements, we may also disclose your health information in response to a subpoena.


LAW ENFORCEMENT:  We may release your health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.  


CORONERS, MEDICAL EXAMINERS AND FUNERAL DIRECTORS:  We may release your health information to a coroner or medical examiner.  This may be necessary, for example, to identify a deceased person or determine the cause of death.


INFORMATION NOT PERSONALLY IDENTIFIABLE:  We may use or disclose your health information in a way that does not personally identify you or reveal who you are.


FAMILY AND FRIENDS:  We may disclose your health information to your family members if we obtain your verbal or written agreement to do so or if we give you an opportunity to object to such a disclosure and you do not raise an objection.  We may also disclose health information to your family or friends if we can infer from the circumstances, based on our professional judgement that you would not object.  For example, we may assume you agree to our disclosure of your persona health information to your family when you bring your family with you into the exam room during treatment or discussion of treatment.


In situations when you are not capable of giving consent (because you are not present or due to your incapacity or medical emergency), we may, using our professional judgement, determine that a disclosure to your family member or friend is in your best interest.  In that situation, we will disclose only health information relevant to the person's involvement in your care.  We may also use our professional judgement and experience to make reasonable inferences that it is in your best interest to allow another person to act on your behalf to pick up, for example, filled prescriptions, medical supplies or x-rays.



We will not use or disclose your health information for any purpose other than those identified in the previous sections without your specific, written Authorization.  We must obtain your Authorization separate from any Consent we may have obtained from you.  If you give us Authorization to use or disclose your health information, you may revoke that Authorization in writing, at any time.  If you revoke your Authorization, we will not longer use or disclose information about you for the reason covered by your written Authorization, but we cannot take back any uses or disclosures already made with your permission.



You have the following rights regarding your health information about you:


RIGHT TO INSPECT AND COPY  You have the right to inspect and copy your health information, such as medical and billing records, that we use to make decisions about your care.  You must submit a written request to the office manager in order to inspect and or copy your health information.  If you request a copy of the information we will charge a fee for the costs of copying, mailing and other associated  supplies.  We may deny your request to inspect and or copy in certain limited circumstances.


RIGHT TO AMEND  If you believe health 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 as long as the information is kept by this office.  To request an amendment, complete and submit a Medical Record Amendment/Correction form to the office manager.  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 the request to amend information that:

  • We did not create
  • Is not part of the health information we keep
  • You would not be permitted to inspect and copy
  • Is accurate and complete

RIGHT TO AN ACCOUNTING OF DISCLOSURES You have the right to request an "accounting of disclosure".  This is a list of the disclosures we made of medical information about you for the purposes other than treatment, payment, and healthcare operatons.  To obtain this list, you must submit your request in writing to the office manager.  It must state a time period, which may not be longer than six years.  We may charge  you for the costs of providing the list and 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 health information we use or disclose about you for treatment, payment or healthcare operations.  You also have the right to request a limit on the health information we disclose about your to someone who is involved in your care or the payment for it, like a family member or friend.  If we do agree to your request, we will comply with your your request unless the information is needed to provide you with emergency treatment.   To request restrictions, you may complete and submit the Request for Restriction On Use/Disclosure of Medical Information to the office manager.


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.  We will accomodate all reasonable requests.  You request must specify how or where you wish to be contacted.  You must make your request in writing.


RIGHT TO A PAPER COPY OF THIS NOTICE   You have the right to a paper copy of this notice at any time.  To obtain a copy, contact office personnel.


CHANGES TO THIS NOTICE We reserve the right to change this notice, and to make the revised or changed notice effective for medidcal information we already have about you as well as any information we receive in the future.  We will post a summary of the current notice in the office with its effective date. You are entitled to a copy of the notice currently in effect.



If you want more information about our privacy practice or have questions or concerns, please contact us.


If you believe your privacy rights have been violated, you may file a complaint with our office or the the Secretary of the Department of Health and Human Services.  To file a complaint with our office, please contact:


Contact Person:  Beth Fitzgerald

Telephone:          765-456-1790

Address:              2000 W. Boulevard

                            Kokomo, IN 46902




Revision Date 11/01/2010

Download a copy of our Patient Privacy Policy