HIPAA Notice of Patient Privacy Practices

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.

We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We create a record of the care and services you receive at the clinic. We need this record to provide you with quality care and to comply with certain legal requirements. This notice applies to all of the records of your care generated or maintained by AMITY MEDICAL GROUP.

This notice will tell you the ways in which we may use and disclose medical information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of medical information.

We Are Required By Law To:

• Use our best efforts to keep medical information that identifies you private
• Give you this notice of our legal duties and privacy practices with respect to medical information about you
• Follow the terms of the notice that currently in effect

How We May Use And Disclose Medical Information About You

The following categories describe different ways that we may use and disclose medical information. Not every use or disclosure in a category will be listed. However, all of the ways we are permitted to use and disclose information will fall within one of the categories.

Treatment – We may use medical information about you to provide you with medical treatment or services. We may disclose medical information about you to the various practitioners within AMITY MEDICAL GROUP to coordinate the different types of care and things you need. We also may disclose medical information about you to people outside AMITY MEDICAL GROUP, who may be involved in you care such as family members.

Health Care Operations – We may use and disclose medical information about you for AMITY MEDICAL GROUP operations. These uses and disclosures are necessary to run AMITY MEDICAL GROUP and make sure that all our patients receive quality care. For example, we may use medical information to review our treatment and services and to evaluate the performance of our practitioners and/or staff caring for you. We may also combine medical information about many patients to decide what additional services AMITY MEDICAL GROUP may provide, what services are not needed, and whether certain new treatments are effective.

Appointment Reminders – We may use and disclose medical information to contact you as a reminder that you have an appointment for treatment or medical care at AMITY MEDICAL GROUP.

Insurance / Reimbursement – We will disclose medical information about you to obtain reimbursement from your insurance company or other entity for the provision of health care.

As Required by Law – We will disclose medical information about you when required to do so by federal, state, or local law.

To Avert a Serious Threat to Health or Safety – We may use and disclose medical information about you when necessary to prevent a serious threat to your health and safety or the health of the public or another person. Any disclosure, however, would only be to someone able to help prevent the threat.

Health Oversight Activities – We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Law Enforcement – We may release medical information if asked to do so by a law enforcement official:

• In response to a court order, subpoena, warrant, summons or similar process
• To identify or locate a suspect, fugitive, material witness, or missing person
• About the victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement

Your Rights Regarding Medical Information About You

Right to Inspect and Copy – You have the right to inspect and copy some of the medical information that may be used to make decisions about your care. If you request a copy of the associated with your request.

Health Oversight Activities – We may disclose medical information to a health oversight agency for activities authorized by law. These oversight activities include, for example, audits, investigations, inspections, and licensure. These activities are necessary for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Right to Amend – If you feel that medical information we have about you is incorrect or incomplete, you may ask us to amend the information. You have the right to request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request.

We may request an amendment if it is not in writing or does not include a reason to support the 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 medical information kept by or for the clinic
• Is not part of the information which you would be permitted to inspect and copy
• Is accurate and complete

Right to an Accounting of Disclosure – You have the right to request an “accounting of disclosures.” This is a list of the disclosures we have made of the medical information about you. Your request must state a time period. Your request should indicate in what form you want the list (for example, on paper, 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 notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred.

Right to Request Restrictions – You have the right to request a restriction or limitation on the medical information we use or disclose about you for treatment, or health care operations. You also have the right to request a limit on the medical information we disclose about you to someone who is involved in your care or the payment for your care, like a family member or friend. In your request, you must tell us:

1. What information do you want to limit
2. Whether you want to limit our use; disclosure or both
3. To whom you want the limits to apply, for example, disclosures to your spouse

Right to Request Confidential Communications – 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 can ask that we only contact you at work or by mail. We will not ask you the reason for your request. We will accommodate all reasonable requests. Your request must specify how or where you wish to be contacted.

Electronic Communication – If you request information to be transmitted electronically, please be advised that your private information may not be protected. AMITY MEDICAL GROUP cannot guarantee that any information you receive from us will be received through a secure network. We will take every step necessary on our end to protect your privacy.

Changes To This Notice

We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you as well as any information we receive in the future. We will post a copy of the current notice in AMITY MEDICAL GROUP. In addition, each time you register, you may obtain a copy of the current notice in effect.

Complaints

If you believe your privacy rights have been violated, you may file a complaint with the clinic or with the Secretary of the Department of Health and Human Services.

You will not be penalized for filing a complaint.

Revoking Permission To Disclose Medical Information

If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.