Notice of Privacy Practices
EFFECTIVE: April 14, 2003

ALL PATIENTS

As part of our patients rights regarding the confidentiality of their medical records, new Federal Government regulations require our practice to give our patients a copy of our Policy of Information Practices. This policy states how information about you may be used and disclosed.

Federal Government regulations also require us to have your signature on file stating that we gave you a copy of our Policy of Information Practices. This is all that the last sheet is used for. This does not replace any required authorizations signed by you in order to have your medical records sent out of our office.

Please sign and date the last sheet and return to our Receptionist to file in your chart.

Thank you for your help in keeping our office in compliance with Federal Rules & Regulations.

Management

Your Health Record
Each time you visit or call the practice of Bradley L. Freilich, M.D., AGAF, LLC a record of your visit is made. Typically, this record contains your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment. This information, often referred to as your health or medical record, serves as a:

• Basis for planning your care and treatment.
  

• Means of communication among the many health professionals who contribute to your care.
  

• Legal document describing the care you received.
  

• Means by which you or a third party payer can verify that services billed were actually provided.
  

• A tool in educating health professionals.
  

• A source of data for medical research.
  

• A source of information for public health officials charged with improving the health of the nation.
  

• A source of data for facility planning and marketing.
  

• A tool with which we can assess and continually work to improve the care we render and the outcomes we achieve.

Understanding what is in your record and how your health information is used helps you to:

• Ensure its accuracy.
  

• Better understand who, what, when, where and why others may access your health information.
  

• Make more informed decisions when authorizing disclosure to others.

Health Information Rights
The information in the health records we maintain belongs to you. You have the right to:

• Request a restriction of certain uses and disclosures of your information.
  

• Obtain a paper copy of the notice of information practices upon request.
  

• Inspect and copy the health record.
  

• Request an amendment of the health records.
  

• Obtain an accounting of disclosures of the health information.
  

• Request communications of your health information by alternative means or at alternative locations.
  

• Revoke your authorization to use or disclose health information except to the extent that action has already been taken

If you have any questions, you may check out this website at http://www.hhs.gov.

Our Responsibilities
This Organization is required to:

• Maintain the privacy of your health information.
  

• Provide you with a notice as to our legal duties and privacy practices with respect to information we collect and maintain about you.
  

• Abide by the terms of this notice.
  

• Notify you if we are not able to agree to a requested restriction.
  

• Accommodate reasonable requests you may have to communicate health information by alternative means or at alternative locations.

We reserve the right to change our practices and to make the new provisions effective for all protected health information we maintain. Should our information practices change, we will mail a revised notice to the address you’ve supplied us.

We will not use or disclose your health information without your authorization, except as described in this notice

If you have any questions, you may contact the office at 816-361-0055. If you believe your privacy rights have been violated, you can file a complaint with the office manager or with the Secretary of Health and Human Services, Office of the Secretary, 200 Independence SW, Washington, DC 20201. There will be no retaliation for filing a complaint.

Examples of Disclosures for Treatment, Payment and Health Operations:
We will use your health information for treatment. For example: Information obtained by a nurse, physician or other member of your healthcare team will be recorded in your record and used to determine the course of treatment that should work best for you. Your physician will document in your record his expectations of the members of your healthcare team. Members of your healthcare team will then record the actions they took and their observation. In that way the physician will know how you are responding to the treatment. We will also provide your physician or a subsequent healthcare provider with copies of various reports that should assist him/her in treating you.

We will use your health information for payment. For example: A bill may be sent to you or a third party payer. The information on or accompanying the bill may include information that identifies you, as well as your diagnosis, procedures and supplies used.

We will use you health information for regular health operations. For example: Members of the medical staff, the risk or quality improvement manager, or members of the quality improvement team may use information in your health record to assess the care and outcomes in your case and others like it. This information will then be used in an effort to continually improve the quality and effectiveness of the healthcare and service we provide.

Other Uses or Disclosures
Business Associates: There are some services provided in our organization through contacts with business associates. Examples include physician services in the Emergency Department and Radiology, and certain laboratory tests. When these services are contracted, we may disclose your health information to our business associate so that they can perform the job we’ve asked them to do and bill you or your thid party payer for services rendered. So that your health information is protected, however, we require the business associate to appropriately safeguard your information.

Notification: We may use or disclose information to notify a family member or another person responsible for your care or payment.

Communication with family: Health professionals, using their best judgement, may disclose to a family member, other relative or any other person you identify, health information relevant to that person’s involvement in your care or payment related to your care.

We may contact you by phone and/or mail to provide appointment reminders.

Food and Drug Administration (FDA): We may disclose to the FDA health information relative to adverse events with respect to food, supplements, product and product defects or post marketing surveillance information to enable product recalls, repairs or replacement.

Public Health: As required by law, we may disclose health information to public health or legal authorities charged with preventing or controlling disease, injury or disability.

Correctional Institution: Should you be an inmate of a correctional institution, we may disclose to the institution or agents thereof, health information necessary for your health, and the health and safety of other individuals.

Law Enforcement: We may disclose health information for law enforcement purposes as required by law, or in response to a valid subpoena.

Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority or attorney, provided that a workforce member or business associate believes in good faith that we have engaged in unlawful conduct or have otherwise violated professional or clinical standards are potentially endangering one or more patients, workers or the public.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
** You may refuse to sign this acknowledgement**

I, ___________________________________________, have been provided with a copy of the notice of privacy practices.

______________________________________________________________________________________________
Signature

Date: ___________________________

Permission to Disclose Information
I hereby allow the practice of Bradley L. Freilich, M.D., AGAF, L.L.C. to disclose test results to the following people:

                  Self       Spouse       Other

in the following forms of communication:

                Home telephone       Home voice messaging system
                Work telephone         Work voice messaging system
                Cellular phone           Mail


________________________________________________________________________________________________
Signature

Date: ________________________

For Office Use Only

We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:

• Individual refused to sign.
  

• Communication barriers prohibited obtaining the acknowledgement.
  

• An emergency situation prevented us from obtaining acknowledgement.
  

• Other (please specify)