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and how you can get access to this information. Please review it carefully! With your consent, the practice is permitted by federal privacy laws to make uses and disclosures of your health information for purposes of treatment, payment, and health care operations. Protected health information is the information we create and obtain in providing our services to you. Such information may include documenting your symptoms, examination and test results, diagnoses, treatment and applying for future care or treatment. It also includes billing documents for those services. Example of uses of your health information for treatment purposes: A nurse obtains treatment information about you and records it in a health record. During the course of your treatment, the doctor determines a need to consult with another specialist in the area. The doctor will share the information with such a specialist and obtain input. Example of use of your health information for payment purposes: We submit a request for payment to your health insurance company. The health insurance company requests information from us regarding medical care given. We will provide information to them about you and the care given. Example of use of your Information for Health Care Operations: We obtain services from your insurers or other business associates such as quality assessment, quality improvement, outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal services and insurance. We will share information about you with such insurers or other business associates as necessary to obtain these services. Your Health Information Rights The health record we maintain and billing records are the physical property of the practice. The information in it, however, belongs to you. You have a right to: the request in writing to our office. We are not required to grant the request but we will comply with any request granted; ("Notice") by making a request at our office; - you may exercise this right by delivering the request in writing to our office; information by delivering a written request to our office; amendment and any denial be attached in all future disclosures of your protected health information; by delivering a written request to our office. An accounting will not include internal uses of information for treatment, payment or operations, disclosures made to you or made at your request, or disclosures made to family members or friends in the course of providing care; location by delivering the request in writing to our office; and previously to use or disclose information except to the extent information or action has already been taken by delivering a written revocation to our office. in person or in writing, during normal hours. He will provide you with assistance on the steps to take to exercise your rights. You have the right to review this Notice before signing the consent authorizing use and disclosure of your protected health information for treatment, payment, and health care operations purposes. Our Responsibilities The practice is required to: about you; We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact new provisions regarding the protected health information we maintain. If our information practices change, we will amend our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our "Notice" or by visiting our office and picking up a copy. To Request Information or File a Complaint If you have questions, would like additional information, or want to report a problem regarding the handling of your information, you may contact Dr. Frank Falcone, Jr. (570) 455-5889. Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our office by delivering the written complaint to Dr. Frank Falcone, Jr. You may also file a complaint by mailing it or e-mailing it to the Secretary of Health and Human Services whose street address and e-mail address is The Public Ledger Building, 150 S. Independence Mall West, Philadelphia, PA 19106-3499, (215) 861-4633. Human Services (HHS) as a condition of receiving treatment from the practice. Other Disclosures and Uses Notification Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member personal representative, or other person responsible for your care, about your location, and about your general condition, or your death. Communication with Family Using your best judgement, we may disclose to a family member, other relative, close personal friend, or any other person you identify, health information relevant to that person’s involvement in your care or in payment for such care if you do not object or in an emergency. Food and Drug Administration (FDA) We may disclose to the FDA your protected health information relating to adverse events with respect to products and product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements. Workers Compensation If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the extent necessary to comply with laws relating to Workers Compensation. Public Health As required by law, we may disclose your protected health information to public health or legal authorities charged with preventing or controlling disease, injury, or disability. Abuse & Neglect We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect. Correctional Institutions If you are an inmate of a correctional institution, we may disclose to the institution, or its agents, your protected health information necessary for your health and the health and safety of other individuals. Law Enforcement We may disclose your protected health information for law enforcement purposes as required by law, such as when required by a court order, or in cases involving felony prosecutions, or the extent an individual is in the custody of law enforcement. Health Oversight Federal law allows us to release your protected health information to appropriate health oversight agencies or for health oversight activities. Judicial/Administrative Proceedings We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or required by law, with your consent, or as directed by a proper court order. Other Uses Other uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law or with your written authorization and you may revoke the authorization as previously provided. Website If we maintain a website that provides information about our entity, this Notice will be on the website. Research review board that has reviewed the research proposal and established protocols to ensure the privacy of your protected health information. Disaster Relief Funeral Directors/Coroners applicable law to allow them to carry out their duties. Organ Procurement Organizations organizations of other entities engaged in the procurement, banking or transplantation of organs for the purpose of tissue donation and transplant. Marketing other health-related benefits and services that may be of interest to you. Fund Raising For Specialized Governmental Functions such as to Armed Forces personnel, for national security purposes, or to public assistance program personnel. Effective Date: 10/1/2002 |