THIS NOTICE DESCRIBES HOW INFORMATION

ABOUT YOU MAY BE USED AND DISCLOSED AND HOW

YOU CAN GAIN ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY<?xml:namespace prefix = o /> 

1. FAMILY MEDICINE, INC., may use and disclose protected health information for treatment,

payment, and healthcare operations.  Examples of these include, but are not limited to, 

requested preschool, life insurance, or sports physicals, or referral to other providers for 

treatment.  Payment examples include, but are not limited to, internal quality control and 

assurance including auditing of records.

2. FAMILY MEDICINE, INC. is permitted or required to use or disclose protected health 

information without the individual’s written authorization in certain circumstances.  Two 

examples of such are for public health requirements or court orders. We may also release 

protected health information about you for workers compensation or similar programs.

3. FAMILY MEDICINE, INC. will not make any other use or disclosure of a patient’s protected 

health information without the patient’s written authorization.  Such authorization may be 

revoked at anytime. Revocation must be in writing.

4. FAMILY MEDICINE, INC. may at times contact the patient to provide appointment 

reminders or information regarding services that may be of interest to the individual patient.

5. You will be provided a form to list specific people (family or friends) who we may speak to 

regarding your medical care.  In addition, we may disclose protected health information about 

you to an entity assisting in a disaster relief effort so that your family can be notified about 

your condition, status, and location.

6. FAMILY MEDICINE, INC. will abide by the terms of this notice or the notice currently in 

effect at the time of the disclosure.

7. FAMILY MEDICINE, INC. reserves the rights to change the terms of its notice and to make 

new notice provisions effective for all protected health information that it maintains.

8. FAMILY MEDICINE INC. will provide each patient with a copy of the revisions of its 

Notice of Privacy Practice at the time of their next visit, or at their last known address if there 

is a need to use or disclose protected health information of the patient. Copies may also be 

obtained at anytime at our office.

9. Any person/patient may file a complaint to the practice and/or to the Department of Health 

and Human Services, Office of Civil Rights, if they believe their privacy rights have been 

violated. To file a complaint with the practice please contact the office manager/office 

administrator.  All complaints will be addressed and the results will be reported to the 

Managing Physician.

10. It is our policy that no retaliatory action will be made against any individual who submits 

or conveys a complaint of suspected or actual non-compliance of the privacy standards.

Patients have been granted individual rights under the HIPAA Legislation. These include the 

following:

1. You have the right to inspect and copy protected health information that may be used to 

make decisions about your care. Usually, this includes medical and billing records, but does 

not include psychotherapy notes, information compiled in reasonable anticipation of or us in a

civil, criminal, or administrative action or proceeding, or protected health information that is 

subject to or exempt from the Criminal Liberties Act of 1988. To inspect and copy protected 

health information that may be used to make decisions about you, you must submit your 

request in writing to the privacy officer. If you request a copy of the information, we may c

harge a fee for the costs of copying, including labor, mailing, or other supplies associated 

with your request.

2. If you feel that protected 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 for as 

long as the information is maintained in the designated record set. To request amendment, 

your request must be made in writing and submitted to the privacy officer. You must provide a 

reason that supports your request and we may deny your request for amendment if it is not in 

writing or does not include a reason to support your request. In addition, we may deny your 

request if you ask us to amend information that was not created by us, unless the person or 

entity that created the information is no longer available to make the amendment, is not part 

of the protected health information kept by or from our practice, is not part of the information 

which you would be permitted to inspect and copy, or is accurate and complete. We may deny 

your request to inspect and copy in very limited circumstances. If you are denied access to 

protected health information, you may request that the denial be reviewed. Another licensed 

healthcare professional chosen by our organization will review your request and denial. The 

person conducting the review will not be the person who denied your request and we will 

comply with the outcome of the review.

3. You have the right to request an “accounting of disclosures.” This is the list of the 

disclosures we made of protected health information that was not made for treatment, payment,

or healthcare operations, there are certain exceptions to this right. To request this list or 

accounting of disclosures, you must submit your request in writing to the privacy officer. 

Your request must state a time period, which may not be longer than six years and may not 

include dates before April 13, 2003. Your request should indicate in what form you want the 

list, for example on paper or electronically. The first list you request within a 12 month period 

will be free. For additional lists, we may charge you for the costs of providing the list. We will 

modify your request at that time before any costs are incurred. The accounting must be 

provided to you no later than 60 days after the receipt of your request, unless we utilize the 

30-day extension period.

4.         You have a right to request a restriction or limitation on the protected 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 information we disclose about you to someone who is 

involved in your care or the payment of your care, like family members or friends. We are not 

required to agree to your request. If we do agree, we will comply with your request unless the 

information is needed to provide you with emergency treatment. To request restrictions, you 

must make the request in writing to the privacy officer. In your request you must tell us 

1) what information you want to limit; 2) to whom you want the limits to apply, for example 

disclosures to your spouse. Either you or we may terminate the restriction upon notification 

from the other.

5.         You have the right to request that we communicate with you about medical matters in a 

certain way or at a certain location. For example, you may ask that we only contact you at work

 or by mail. To request confidential communications, you must make a written request to the 

privacy officer. We will not ask you the reason for the request. We will accommodate all 

reasonable requests. Your request must specify how or where you wish to be contacted.

You will be asked to sign an acknowledgement of receipt of the Notice of Privacy Practices. 

You will also be asked to outline or define specific instances or information that you would 

like kept completely confidential (between you and the organization). If you have any 

questions regarding this Notice of Privacy Practices, please do not hesitate to contact our 

privacy officer.