DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED ANDDISCLOSED AND HOW
YOU CAN GET ACCESS TO THIS INFORMATION.PLEASE REVIEW IT
The Health Insurance Portability & Accountability act of 1996
("HIPAA") is a federal program that requires that all medical records and
other individually identifiable health information used or disclosed by us in
any form, whether electronically, on paper, or orally, are kept properly confidential. This
Act gives you, the patient, significant new rights to understand and control
health information is used. "HIPAA" provides penalties for covered
entities that misuse personal
As required by "HIPAA", we have prepared this explanation of
how we are required to maintain the privacy of your health information and how
we may use and disclose your health information.
We may use and disclose your medical records only for each of the
following purposes: treatment, payment
and health care operations.
• Treatment means providing,
coordinating, or managing health care and related services by one or more
health care providers. An example of this would include an eye examination.
• Payment means such activities
as obtaining reimbursement for services, confirming coverage, billing or
collection activities, and utilization review. An example of this would be
sending a bill for your visit
to your insurance company for payment.
• Health care operations
the business aspects of running our practice, such as conducting quality
assessment and improvement activities, auditing functions, cost-management
analysis, and customer service. An example would be an internal quality assessment
We may also create and distribute de-identified health information by
removing all references to individually identifiable information.
We may contact you to provide appointment reminders or information about
treatment alternatives or other health-related benefits and services that may be of interest to
Any other uses and disclosures will be made only with your written
authorization. You may revoke such authorization in writing and we are required
to honor and abide by that written request, except to the extent that we have already taken actions relying
on your authorization.
You have the following rights with respect to your protect health
information, which you can exercise by presenting a written request to the Privacy Officer:
• The right to request
restrictions on certain uses and disclosures of protected health information, including those
related to disclosures to family members, other relatives, close personal
friends, or any other person identified by you. We are, however, not required to
agree to a requested restriction. If we do agree to a restriction, we must
abide by it unless you agree in writing to remove it.
• The right to
reasonable requests to receive confidential communications of protected health information from us by alternative means
or at alternative locations.
• The right to inspect
and copy your protected health information.
• The right to amend
your protected health information.
• The right to receive
an accounting of disclosures or protected health information.
• The right to obtain a
paper copy of this notice from us upon request. Fgv
We are required by law to maintain the privacy of
your protected health information and to provide you with notice of our legal duties and privacy practices
with respect to protected health information.
This notice is effect as of April 14, 2003 and we
are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right
to changes the terms of our Notice of Privacy Practices and to make the new notice provisions effective for
all protected health information that we maintain. We will post and you may
request a written copy of revised Notice of Privacy Practices from this office.
You have recourse if you feel that your privacy
protections have been violated. You have the right to file written complaint with our office, or with the
Department of Health & Human Services, Office of Civil Rights, about
violations of the provisions of this notice or the policies and procedures of
our office. We will not retaliate against you for filing a
Please contact us for more information:
Sigmund S. Gould, MD
405 Parkway Suite B Greensboro, NC 27401 336-274-2441
ATTN: Lynn Williams
For more information about HIPAA or to file a complaint:
The U.S. Department of Health & Human
Office of Civil Rights
200 Independence Avenue, S.W.