NOTICE OF PRIVACY PRACTICES
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Effective Date 09/23/2043 Publication Date 09/23/2013
This notice describes how medical information about you may be used and disclosed,
and how you can gain access to this information, Please review it carefully.
NEXTLEVEL COMPLETE FAMILY CARE, INC.
Protected health information [FH1), about yor, is maintained as a written and/or electronic record of your contacts or visits for healthcare services with our practice. Specifically, PH! is information about you, including demographic information (L.e., name, address, phone. etc.), that may identify you and relate to your past, present or future physical or mental health condition and related healthcare Services.
Our practice is required to follow specific rules on maintaining the confidentiality of your PH, using your information, and disclosing or sharing this information with other healthcare professionals involved in your care and treatment. This Notice describes your rights to access and control your PH, lt also describes how we follow applicable rules and use and disclose your PHI to provide your treatment, obtain payment for services you receive, manage our healthcare operations and for other purposes that are permitted or required by law.
Your Rights Under The Privacy Rule
Following is a statement of your rights, under the Privacy Rule, in reference to your PHL Please feel free to discuss any questions with our staff.
You have the right to receive, and we are required to provide you with, a copy of thls Notice of Privacy Practices
We are required to follow the terms of this notice, We reserve the right to change the terms of our notice, at any time. Upon your request, we will provide you with a revised Notice of Privacy Practices ¡you call our office and request that a revised copy be sent to you ln the mall or ask for one at the time of your next appointment, The Notice will also be posted in a conspicuous location within the practice, and if such is maintained by the practice, on It's web site.
You have the right to authorize other use and disclosure
This means you have the right to authorize any use or disclosure of PHI that is not specified within this notice, For example, we would need your written authorization to use or disclose your PHI for marketing purposes, for most uses or disclosures of psychotherapy notes, or if we intended to sell your PHI, You may revoke an authorization, at any time, in writing, except to the extent that your healthcare provider, or our practice has taken an action in reliance on the use or disclosure indicated in the authorization.
You have the right to request an alternative means of confidential communication This means you have the right to ask us to contact you about medical matters using an alternative method (l.e., email, telephone), and to a destination (i.e., cell phone number, alternative address, etc.) designated by you. You must inform us in writing, using a form
provided by our practice, how you wish to be contacted if other than the address/phone number that we have on file. We will follow all reasonable requests.
You have the right to inspect and copy your PHI
This means you may inspect, and obtain a copy of your complete health record. lf your health record is maintained electronically, you will also have the right to request a copy in electronic format. We have the right to charge a reasonable fee for paper or electronic copies as established by a professional, state, or federal? guidelines.
You have the right to request a restriction of your PHI
This means you may ask us, in writing, not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. If we agree to the requested restriction, we will abide by il, except in emergency circumstances
when the Information is needed [or your treatment. In certain cases, we may deny your request for a restriction. You will have the right to request, inwriting, thal we restrict communication to your health plan regarding a specific treatment or service that you, or someone On your behalf, has paid for in full, vut-of-pocket. We are not entitled to deny this specific type of requested restriction.
You may have the right to request an amendment to your protected health Information
This means you may request an amendment of your PH for as long as we maintain this information In certain cases, we may deny your request.
You have the right to request a disclosure accountability
This means that you may request a fisting of disclosures that we have made, of your PEI, to entities or persons outside of our office.
You have the right to receive a privacy breach notice :
You have the right to receive written notification all the practice discovers a breach of your unsecured PHI, and determines through a risk assessment that notification is required.
If you have questions regarding your privacy rights, please feel free to contact our Privacy Manager. Contact information is provided on the following page under Privacy Complaints.
