THIS OFFICE IS IN COMPLIANCE WITH THE FEDERAL HIPAA
GUIDELINES FOR PRIVACY
NOTICE OF 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.
Your health information may be used by staff members or disclosed to other health care professionals for the purpose of evaluating your health, diagnosing and providing treatment.
Your health information may be used as necessary to support the day-to-day activities and management of Finally Health Medical Servies, PC (FHMS).
Your health information may be disclosed to law enforcement agencies and or public health agencies, to support government audits & inspections, to facilitate law-enforcement investigations, and to comply with government mandated reporting (such as public health reporting of communicable diseases).
Use or disclosure of your health information for any other purpose other than those listed above requires your written authorization. If you change your mind after authorizing a use or disclosure of your information you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision.
In addition, your health information maybe used by our staff to send you appointment reminders, and/or information on the treatment and management of your medical condition.
You have certain rights under the federal privacy standards. These include: 1) The right to request restrictions on the use and disclosure of your protected health information. 2) The right to receive confidential communications concerning your medical condition. 3) The right to inspect and copy your protected health information. 4) The right to amend or submit corrections to your protected health information. 5) The right to receive an accounting of how and to whom your protected health information has been disclosed. 6) The right to receive a printed copy of this notice.
FHMS.is required by law to maintain the privacy of your information and to provide you with this notice. We reserve the*right to amend or modify our privacy policies and practices as permitted by law. Any changes may be mandated by changes in federal law. If any changes occur, we will provide you with a revised notice upon your next visit. The revised notice will apply to all protected health information that we maintain.
You may generally inspect or copy the protected health information we maintain. As permitted by federal regulations, we require that all requests to inspect or copy protected health information be submitted in writing.
If you have any comments or complaints about our privacy practices, or if you feel like your privacy rights have been violated, please contact us in writing, or address the issue with our office manager in person. Our contact address is: 3500 Nostrand Avenue, Brooklyn, NY 11229 (718)769-2521.
This notice is effective as of December 1, 2002.
FINALLY HEALTH MEDICAL SERVICES, PC
3500 Nostrand Avenue, Brooklyn, NY 11229
(718) 769-2521 - Fax (718) 646-1911
Acknowledgement of Receipt of Notice of Privacy Practices
Finally Health Medical Services, PC reserves the right to modify the privacy practices outlined in the notice.
I have received a copy of the Notice of Privacy Practices for Finally Health Medical Services, PC.
Name of Patient (Print or Type): ___________________________________________________________
Signature of Patient: ___________________________________________________________________
Signature of Patient Representative: ______________________________________________________
(Require if the patient is a minor or an adult who is unable to sign this form)
Relationship of Patient Representative to Patient: ____________________________________________