HIPPA Privacy Practices
Notice of Privacy Practices
Last Revision January 1, 2014
Arbor Family Medicine
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.
The Health Insurance Portability & Accountability Act of 1996 (HIPAA) requires all health care records and other
individually identifiable health information (PROTECTED HEALTH INFORMATION) used or disclosed to us in
any form, whether electronically, on paper, or orally, be kept confidential. This federal law gives you, the patient,
significant new rights to understand and control how your health information is used. HIPAA provides penalties for
covered entities that misuse personal health information. 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
Without specific written authorization, we are permitted to use and disclose your health care records for the
purposes of treatment, payment and health care operations.
- Treatment means providing, coordinating, managing health care and /or related services by one or more health
care providers. Examples of treatment would include office visits, x-rays, wart removal, office surgery etc.
- Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection
activities, and utilization review. An example of this would be billing your medical plan for your medical services.
- Health Care Operations include 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 include a periodic assessment of our documentation protocols, etc.
In addition, your confidential information may be used to remind you of an appointment (by phone or mail) or
provide you with information about treatment options or other health-related services including release of
information to friends and family members that are directly involved in your care or who assist in taking care of you.
We will use and disclose your PROTECTED HEALTH INFORMATION when we are required to do so by federal,
state or local law. We may disclose your PROTECTED HEALTH INFORMATION to public health authorities that
are authorized by law to collect information (i.e the Centers for Disease Control) or to a health oversight agency for
activities authorized by law included but not limited to: response to a court or administrative order, if you are
involved in a lawsuit or similar proceeding, response to a discovery request, subpoena, or other lawful process by
another party involved in the dispute, but only if we have made an effort to inform you of the request or to obtain an
order protecting the information the party has requested. We will release your PROTECTED HEALTH
INFORMATION if requested by a law enforcement official for any circumstance required by law. We may release
your PROTECTED HEALTH INFORMATION to a medical examiner or coroner to identify a deceased individual
or to identify the cause of death. If necessary, we also may release information in order for funeral directors to
perform their jobs. We may release PROTECTED HEALTH INFORMATION to organizations that handle organ,
eye or tissue procurement or transplantation, including organ donation banks, as necessary to facilitate organ or
tissue donation and transplantation if you are an organ donor. We may use and disclose your PROTECTED
HEALTH INFORMATION when necessary to reduce or prevent a serious threat to your health and safety or the
health and safety of another individual or the public. Under these circumstances, we will only make disclosures to a
person or organization able to help prevent the threat. We may disclose your PROTECTED HEALTH
INFORMATION if you are a member of U.S. or foreign military forces (including veterans) and if required by the
appropriate authorities. We may disclose your PROTECTED HEALTH INFORMATION to federal officials for
intelligence and national security activities authorized by law. We may disclose PROTECTED HEALTH
INFORMATION to federal officials in order to protect the President, other officials or foreign heads of state, or to
conduct investigations. We may disclose your PROTECTED HEALTH INFORMATION to correctional institutions
or law enforcement officials if you are an inmate or under the custody of a law enforcement official. Disclosure for
these purposes would be necessary: (a) for the institution to provide health care services to you, (b) for the safety
and security of the institution, and/or (c) to protect your health and safety or the health and safety of other
individuals or the public. We may release your PROTECTED HEALTH INFORMATION for workers'
compensation and similar programs.
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 certain rights in regards to your PROTECTED HEALTH INFORMATION, which you can exercise by
presenting a written request to our Privacy Officer at the practice address listed below:
- 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 request to receive confidential communications of PROTECTED HEALTH INFORMATION from us
by alternative means or at alternative locations.
- The right to request a copy of your PROTECTED HEALTH INFORMATION (charges for the copying are subject
to state requirements).
- The right to request an amendment to your PROTECTED HEALTH INFORMATION.
- The right to receive an accounting of disclosures of PROTECTED HEALTH INFORMATION outside of
treatment, payment and health care operations.
- The right to obtain a paper copy of this notice from us upon request.
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.
We are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to
change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all
PROTECTED HEALTH INFORMATION that we maintain. Revisions to our Notice of Privacy Practices will be
posted on the effective date and you may request a written copy of the Revised Notice from this office.
You have the right to file a formal, written complaint with us at the address below, or with the Department of Health
& Human Services, Office of Civil Rights, in the event you feel your privacy rights have been violated. We will not
retaliate against you for filing a complaint.
For more information about our Privacy Practices or to file a complaint, please contact:
Arbor Family Medicine, PC
3655 E 104th Avenue
Thornton, CO 80233
For more information about HIPAA or to file a complaint:
The U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington, D.C. 20201