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NOTICE OF PRIVACY PRACTICES FOR
ROBERT M. GORDON, PH.D., ABPP, PC
THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED
AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
At our office of Robert M. Gordon, Ph.D., ABPP, PC, we are committed to treating
and using protected health information about you responsibly. This notice of
Health Information Practices describes the personal information we collect,
and how we use or disclose that information. It also describes your rights as
they relate to your protected health information. This notice is effective 04/07/03
and applies to all protected health information as defined by federal regulations.
Understanding Your Health Record/Information
Each time you visit our practice; a record of your visit is made. Typically,
this record contains your symptoms, examination, test results, diagnoses, treatment,
and a plan for future care or treatment. This information, often referred to
as your health or medical record, serves as a:
• Basis for planning you care and treatment.
• Legal document describing the care you received.
• Tool in educating health professionals.
• Source of information for public health officials charged with improving
the health of this state and nation.
• Tool with which we can access and continually work to improve the care
we render and the outcomes we achieve.
• Means for communication among the many health professions who contribute
to your care.
• Means by which you or a third-party payer can verify the services billed
were actually provided.
• Source of data for medical research.
• Activities conducted to obtain payment for your cure.
Understanding what is in your record and how your health information is used
helps to: ensure its accuracy, better understand who, what, when, where and
why others may access your health information, and make more informed decisions
when authorizing disclosure to others.
Your Health Information Rights
• Obtain a paper copy of this notice of information upon request.
• Amend your health record as provided in 45 CFR 164.528.
• Request communications of your health information by alternative means
• Revoke authorization to use or disclose health information except to
the extent that action has already been taken.
• Inspect and copy your health record as provided for in 45 CFR 164.524.
• Obtain an accounting of disclosures of your health information as provided
of your health information as provided in 45 CFR 164.528.
• Request a restriction on certain used and disclosure of your information
as provided by 45 CFR 164.522.
• We have the right to charge for work and copying for the above.
Robert M. Gordon, Ph.D., ABPP, PC is required to:
• Maintain the privacy of your health information.
• Abide by the terms of this notice.
• Accommodate reasonable requests you may have to communicate health information
by alternative means or locations.
• Provide you with this notice as to our legal duties and privacy practices
with respect to information we collect and maintain about you.
• Notify you if we are unable to agree to a requested restriction.
We reserve the right to change our practices and to make the new provisions
effective for all protected health information we maintain. Should our information
practices change, we will post a revised notice in the office.
We will not use or disclose your health information without your authorization,
except in this notice. We will also discontinue to use or disclose your health
information after we have received a written revocation of the authorization
according to the procedures included in the authorization.
To Report a Problem
If you believe your privacy rights have been violated, you can file a complaint
with our practice’s Privacy Officer, or with the Office for Civil Rights,
U.S. Department of Health and Human Services. There will no retaliation for
filing a complaint with either the Privacy Officer or the Office of Civil Rights.
Examples of Disclosure for Treatment, Payment, and Health Options
We will use your health information for treatment:
For example: Information obtained by other members of your health care team
will be recorded in your record and used to determine the course of treatment
that should work best for you. Your provider will document his or her expectation
of your treatment. This way, the provider will know how you are responding to
treatment. We will also provide your physician or subsequent health care provider
with copies of various reports that should assist him or her in treating you
one you’re discharged.
We will use your health information for payment:
For example: A bill may be sent to you or a third-party payer. The information
on or accompanying the bill may include information that identifies you, as
well as your diagnosis, procedure and tests used.
We will use your health information for regular health operations:
Business associates: There are some services provided in our organization through
contacts with business associates. Examples include the giving and scoring of
Workers Compensation and No Fault: We may disclose health information to the
extent authorized by and to the extent necessary to comply with laws relating
to workers compensation, no fault insurance or other similar programs established
We can only release your psychotherapy notes, reports, and tests with your
release or by Court Order.