Burt Greenberg, MD
833 Northern Blvd Suite #230
Great Neck, NY 11021
516- 466-6600
NOTICE:
Effective 4/14/03: How Medical information about you may be used and
disclosed ; how you access this information. Please review.
The
privacy of your medical information is important to us. You may be aware
that U.S. government regulations established a privacy rule (ÒHIPPAÓ)
governing health information. This notice tells you about how it may
be used and about certain rights that you have. The manager is in charge
of privacy matters. You can contact her if you desire further information
or have any questions or concerns.
Use and disclosure of protected information
Federal law provides that we may use your medical information
( protected health information) for treatment of you, without further
specific notice to you or written authorization by you; for example,
if we refer you to another specialist, we may provide laboratory or
other test data to that specialist.
Federal law provides that we may use your medical information
to obtain payment for our services without further specific notice to
you, or written authorization by you, for example; under your health
plan, we are required to provide them with a diagnosis code for your
visit and a description of the services rendered.
Federal law provides that we may use your medical information
for health care operations without further specific notice to you, or
written authorization by you; for example, our accountants may see your
name, dates of treatment and procedure codes during audits of our books
We may use or disclose your medical information without
further notice or specific authorization by you, when:.
1. required by law
2. required for public health purposes
3.
required by law to report
child abuse
4.
required by a health oversight
agency for oversight authorized by law, such as the Dept of Health;
Office of Professional Misconduct or Office of Professional Discipline
5.
required by law for enforcement
purposes by a law enforcement official
6.
required by law in judicial
or administrative proceedings
7.
required by a coroner
or medical examiner
8.
permitted by law to a
funeral director
9.
permitted by law for organ
donation purposes
10.
permitted by law to avert
a serious threat to health or safety
11.
permitted by law and required
by military authorities if you are a member of the armed forces of the
U.S.
New York State law provides additional protection for
information regarding HIV/AIDS. We will continue to follow New York
State Law with respect to such information. We may contact you by mail
or by phone, at your residence, to remind you of appointments or to
provide information about treatment alternatives. Unless you instruct
us otherwise, we may leave a message, with minimal medical information,
for you on any answering device or with any person who answers the telephone
at your residence. You can make reasonable requests, in writing, for
us to use alternative methods of communicating with you in a confidential
manner. Space for this is provided below.
Other uses or disclosures of your medical information
will be made only with your written authorization. You have the right
to revoke any written authorization that you give.
Rights that
you have.
You have the right to request restrictions of certain disclosures described
above. Except as stated below, we are not required to agree to such
restrictions.
You have the right to obtain copies of your medical information.
A fee of $.75 per page will be charged
You have the right to request amendments to your medical
information. Such requests must be in writing and must state the reason
for the requested amendment. We will notify you as to whether we agree
or disagree with the requested amendment. If we disagree with any requested
amendment, we will further notify you of your rights.
You have the right to request an accounting of any disclosures
we make of your medical information, except for: disclosures we make
to you or to carry out treatment, payment or health care operations,
or; as requested by your written authorization, or as permitted or required
under 45 CFR B 164.502, or for emergency or notification purposes, or
for national security or intelligence purposes as permitted by law;
or to correctional facilities or law enforcement officials as permitted
by law or disclosures made before 4/14/03
Obligations that we have:
We are required by law to maintain the privacy of protected health information
and to provide individuals with notice of our legal duties and privacy
practices
We reserve the right to revise this notice and to make
a new notice effective for all protected health information we maintain.
Any revised notice will be posted in our office and copies will be available
there
If you want to complain about violations of your privacy
rights, you have the right to file this complains with the Secretary
of the Department of Health and Human Services of the United States.
You may also file a complaint with us
Parent /Legal Guardian ( Signature)
Date
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