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.

Treatment, Payment and Health Care Operations

Joseph M. Perlman, M.D. , P.A. uses and discloses your protected health information, payment and health care operations.

Some examples of when our office may use or disclose your health care information for these purposes include:

• Sharing test results with other health care providers for confirmation of a diagnosis;

• Providing your diagnosis or other information about your health to your insurance provider or out billing service to obtain payment for the health care services we provide;

• Reviewing information as part of our quality improvement program.

Other Uses and Disclosures

Joseph M. Perlman, M.D. , P.A. may also use or disclose your protected health information, in compliance with guidelines outlined by law, for the following purposes:

• Providing you with information related to your health;

• Contacting you regarding appointments, information about treatment alternatives, or other health related services;

• Incidental uses or disclosures (listing your name on a sign-in sheet, etc.)

• Compliance with all laws (including reports of suspected abuse, neglect or violence);

• Providing certain specified information to law enforcement or correctional institutions;

• Providing information to a coroner, medical examiner, funeral director, or organ procurement organization;

• Public health activities when requested by a public health authority or the FDA;

• Responding to health oversight agencies;

• Responding to court administrative tribunal orders, subpoenas, discovery requests or other lawful process;

• Research activities;

• When necessary to avert a serious threat to health of safety;
Military affairs, veteran’s affairs, national security, intelligence, Department of State of Presidential protective service activities;

• Providing information regarding your location, general condition or death to public or private disaster relief agencies; or

• Informing a family member, other relative, or close personal friend when:

• Information is relevant to the individual’s involvement with your care;

• Notification of your location, general condition or death;

• To assist in your health care (e.g., pick-up prescriptions or other documents, note follow-up care instructions, etc.)

Authorization for Other Uses

Joseph M. Perlman, M.D. , P.A. will make other uses and disclosure of your protected health information only after obtaining your written authorization. If you authorize a use not contained in this notice, you may revoke your authorization at any time by notifying us in writing that you wish to revoke your authorization.

Your Rights Regarding the Privacy of Your Health Information

Subject to limitations outlined by law, you have certain rights related to use and disclosure of you r protected health information, including the right to:

• Request restriction on certain uses and disclosures. However, not obligated to agree to requested restrictions.

• Receive confidential communications of protected health information.

• Inspect and copy your protected health information with some limited exceptions;

• Amend your health information;

• Obtain a copy of this notice.

Joseph M. Perlman, M.D. , P.A. Duties Regarding the Privacy of Your Health Information

Subject to limitations outlined by law, Joseph M. Perlman, M.D. , P.A. has certain duties related to your protected health information, including:

• Joseph M. Perlman, M.D. , P.A. is required by law to maintain the privacy of protected health information and to provide individuals with notice of our legal duties and privacy practice with respect to protected health information.

• Joseph M. Perlman, M.D. , P.A. is required to abide by the terms of the privacy notice that is currently in effect.

• Joseph M. Perlman, M.D. , P.A. reserves the right to change the privacy practice described in this notice and to make such change effective for all protected health information. Revised notice will be posted in our office and available upon request.

Concerns

If you believe your privacy rights have been violated, you may make a complaint by contacting the office administrator at 281-655-8200 or the Secretary for the Department of Health and Human Services. No individual will be retaliated against for filing a complaint.

I acknowledge that I have received a copy of this notice regarding the use and disclosure of my health information.

Signature _________________________________________
Date ________________________