HIPAA Notice of Privacy Practices

Mountain View Family Practice, PC

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.

This Notice of Privacy Practices is NOT an authorization. This Notice of Privacy Practices describes how we, our
Business Associates and their subcontractors, may use and disclose your protected health information (PHI) to carry out
treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also
describes your rights to access and control your protected health information. “Protected Health Information” is
information about you, including demographic information, that may identify you and that relates to your past, present or
future physical or mental health condition and related health care services.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our
office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your
health care bills, to support the operation of the physician’s practice, and any other use required by law.
Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your health
care and any related services. This includes the coordination or management of your health care with a third party. For
example, your protected health information may be provided to a physician to whom you have been referred to ensure that
the physician has the necessary information to diagnose or treat you.
Payment: Your protected health information will be used, as needed, to obtain payment for your health care services. For
example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to
the health plan to obtain approval for the hospital admission.
Healthcare Operations: We may use or disclose, as-needed, your protected health information in order to support the
business activities of your physician’s practice. These activities include, but are not limited to, quality assessment,
employee review, training of medical students, licensing, fundraising, and conducting or arranging for other business
activities. For example, we may disclose your protected health information to medical school students that see patients at
our office. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name and
indicate your physician. We may also call you by name in the waiting room when your physician is ready to see you. We
may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment,
and inform you about treatment alternatives or other health-related benefits and services that may be of interest to you. If
we use or disclose your protected health information for fundraising activities, we will provide you the choice to opt out
of those activities. You may also choose to opt back in.
We may use or disclose your protected health information in the following situations without your authorization. These
situations include: as required by law, public health issues as required by law, communicable diseases, health oversight,
abuse or neglect, food and drug administration requirements, legal proceedings, law enforcement, coroners, funeral
directors, organ donation, research, criminal activity, military activity and national security, workers’ compensation,
inmates, and other required uses and disclosures. Under the law, we must make disclosures to you upon your request.
Under the law, we must also disclose your protected health information when required by the Secretary of the Department
of Health and Human Services to investigate or determine our compliance with the requirements under Section 164.500.
USES AND DISCLOSURES THAT REQUIRE YOUR AUTHORIZATION
Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to
object unless required by law. Without your authorization, we are expressly prohibited to use or disclose your protected health
information for marketing purposes. We may not sell your protected health information without your authorization. We may not
use or disclose most psychotherapy notes contained in your protected health information. We will not use or disclose any of
your protected health information that contains genetic information that will be used for underwriting purposes.
You may revoke the authorization, at any time, in writing, except to the extent that your physician or the physician’s practice
has taken an action in reliance on the use or disclosure indicated in the authorization.
YOUR RIGHTS
The following are statements of your rights with respect to your protected health information.
You have the right to inspect and copy your protected health information (fees may apply) – Pursuant to your written
request, you have the right to inspect or copy your protected health information whether in paper or electronic format. Under
federal law, however, you may not inspect or copy the following records: Psychotherapy notes, information compiled in
reasonable anticipation of, or used in, a civil, criminal, or administrative action or proceeding, protected health information
restricted by law, information that is related to medical research in which you have agreed to participate, information whose
disclosure may result in harm or injury to you or to another person, or information that was obtained under a promise of
confidentiality.
You have the right to request a restriction of your protected health information – This means you may ask us not to use or
disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may
also request that any part of your protected health information not be disclosed to family members or friends who may be
involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the
specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to your
requested restriction except if you request that the physician not disclose protected health information to your health plan with
respect to healthcare for which you have paid in full out of pocket.
You have the right to request to receive confidential communications – You have the right to request confidential
communication from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this
notice from us, upon request, even if you have agreed to accept this notice alternatively i.e. electronically.
You have the right to request an amendment to your protected health information – If we deny your request for
amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and
will provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures – You have the right to receive an accounting of
disclosures, paper or electronic, except for disclosures: pursuant to an authorization, for purposes of treatment, payment,
healthcare operations; required by law, that occurred prior to April 14, 2003, or six years prior to the date of the request.
You have the right to receive notice of a breach – We will notify you if your unsecured protected health information has been
breached.
You have the right to obtain a paper copy of this notice from us even if you have agreed to receive the notice electronically.
We reserve the right to change the terms of this notice and we will notify you of such changes on the following appointment.
We will also make available copies of our new notice if you wish to obtain one.
COMPLAINTS
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated
by us. You may file a complaint with us by notifying our Compliance Officer of your complaint. We will not retaliate against
you for filing a complaint.
Sue Simpson 978-939-2133 [email protected]
HIPAA COMPLIANCE OFFICER Phone email

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and
privacy practices with respect to protected health information. We are also required to abide by the terms of the notice
currently in effect. If you have any questions in reference to this form, please ask to speak with our HIPAA Compliance
Officer in person or by phone at our main phone number. Please sign the accompanying “Acknowledgment” form.
Please note that by signing the Acknowledgment form you are only acknowledging that you have received or been given
the opportunity to receive a copy of our Notice of Privacy Practices. Form provided by: HCSI – 801947-0183 – http://www.hcsiinc.com