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FIVE RIVERS OBSTETRICS & GYNECOLOGY H.I.P.P.A. |
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YOUR HEALTH INFORMATION RIGHTS THE HEALTH AND BILLING RECORDS WE MAINTAIN ARE THE PHYSICAL PROPERTY OF THE DOCTOR'S OFFICE. YOU HAVE THE FOLLOWING RIGHTS WITH RESPECT TO YOUR PROTECTED HEALTH INFORMATION: 1. REQUEST A RESTRICTION ON CERTAIN USES AND DISCLOSURES OF YOUR HEALTH INFORMATION BY DELIVERING THE REQUEST IN WRITING TO OUR OFFICE - WE ARE NOT REQUIRED TO GRANT THE REQUEST BUT WE WILL COMPLY WITH ANY REQUEST GRANTED; 2. OBTAIN PAPER COPY OF THE NOTICE OF PRIVACY PRACTICE PROTECTED HEALTH INFORMATION 3. RIGHT TO INSPECT AND COPY YOUR HEALTH AND BILLING RECORD WITH A WRITTEN REQUEST PRESENTED TO OUR OFFICE. 4. RIGHT TO REQUEST THAT YOUR HEALTH RECORD BE AMENDED TO CORRECT INCOMPLETE OR INCORRECT INFORMATION BY DELIVERING A WRITTEN REQUEST TO OUR OFFICE. (THE PHYSICIAN IS NOT REQUIRED TO MAKE SUCH AMENDMENTS); YOU MAY FILE A STATEMENT OF DISAGREEMENT IF YOUR AMENDMENT IS DENIED. 5. RIGHT TO RECEIVE AN ACCOUNTING DISCLOSURES OF YOUR HEALTH INFORMATION AS REQUIRED TO BE MAINTAINED BY LAW 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; 6. RIGHT TO CONFIDENTIAL COMMUNICATION UPON WRITTEN REQUEST. IF YOU WANT TO EXERCISE ANY OF THE ABOVE RIGHTS, PLEASE CONTACT DR. HARRY ZAIN'S OFFICE AT 230 BOWMAN STREET, SUITE B, MORRISTOWN, TENNESSEE, 37813, IN PERSON OR IN WRITING, DURING NORMAL BUSINESS HOURS. THEY WILL PROVIDE YOU WITH ASSISTANCE ON THE STEPS YOU WILL NEED TO TAKE TO EXERCISE YOUR RIGHTS. OUR RESPONSIBILITIES THE OFFICE IS REQUIRED TO: * MAINTAIN THE PRIVACY OF YOUR HEALTH INFORMATION AS REQUIRED BY LAW; * PROVIDE YOU WITH A NOTICE AS TO OUR DUTIES AND PRIVACY PRACTICES AS TO THE INFORMATION WE COLLECT AND MAINTAIN ABOUT YOU; * ABIDE BY THE TERMS OF THIS NOTICE: * ACCOMMODATE YOUR REASONABLE REQUESTS REGARDING METHODS TO COMMUNICATE HEALTH INFORMATION WITH YOU. * ACCOMMODATE YOUR REQUEST FOR ACCOUNTING DISCLOSURES. 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 THE OFFICE AND PICKING UP A COPY. TO REQUEST INFORMATION OR FILE A COMPLAINT IF YOU HAVE QUESTIONS, AND WOULD LIKE ADDITIONAL INFORMATION, OR WANT TO REPORT A PROBLEM REGARDING THE HANDLING OF YOUR INFORMATION, YOU MAY CONTACT DR. HARRY ZAIN'S OFFICE AT 230 BOWMAN STREET, SUITE B, MORRISTOWN, TENNESSEE 37813. ADDITIONALLY, IF YOU BELIEVE YOUR PRIVACY RIGHTS HAVE BEEN VIOLATED, YOU MAY FILE A WRITTEN COMPLAINT AT OUR OFFICE. * WE CANNOT, AND WILL NOT, REQUIRE YOU TO WAIVE THE RIGHT TO FILE COMPLAINT WITH THE SECRETARY OF HEALTH AND HUMAN SERVICES (HHS) AS A CONDITION OF RECEIVING TREATMENT FROM THE OFFICE. * WE CANNOT, AND WILL NOT, RETALIATE AGAINST YOU FOR FILING A COMPLAINT WITH THE SECRETARY OF HEALTH AND HUMAN SERVICES. FOLLOWING IS A LIST OF OTHER USES AND DISCLOSURES ALLOWED BY THE PRIVACY RULE PATIENT CONTACT WE MAY CONTACT YOU TO PROVIDE YOU WITH APPOINTMENT REMINDERS, WITH INFORMATION ABOUT TREATMENT ALTERNATIVES, OR WITH INFORMATION ABOUT OTHER HEALTH-RELATED BENEFITS AND SERVICES THAT MAY BE OF INTEREST TO YOU. NOTIFICATION - OPPORTUNITY TO AGREE OR OBJECT 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 OUR BEST JUDGMENT, 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. WE MAY USE AND DISCLOSE YOUR PROTECTED HEALTH INFORMATION TO ASSIST IN DISASTER RELIEF EFFORTS. OPPORTUNITY TO AGREE OR OBJECT NOT REQUIRED PUBLIC HEALTH ACTIVITIES CONTROLLING DISEASE - 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. CHILD ABUSE & NEGLECT - WE MAY DISCLOSE PROTECTED HEALTH INFORMATION TO PUBLIC AUTHORITIES AS ALLOWED BY LAW TO REPORT CHILD ABUSE OR NEGLECT. |