TETON NUCLEAR MEDICINE SERVICE
Privacy Officer Dan Davis
PROVIDER 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 CAREFULLY.
USES AND DISCLOSURES OF HEALTH INFORMATION
We
use health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate
the quality of care that you receive. Continuity of care is part of treatment and your records may be shared with other providers
to whom you are referred. Information may be shared by paper mail, electronic mail, fax or other methods.
We may use or disclose identifiable health information about you without
your authorization for several reasons. Subject to certain requirements, we may share health information without your authorization
for public health purposes, for auditing purposes, for research studies, and for enforcement in specific circumstances. In
any other situation, we will ask for your written authorization before using or disclosing any identifiable health information
about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop
any future uses and disclosures.
We may change our policies
at any time. Before we make a significant change in our policies, we will change our notice and post the new notice in the
waiting area. You can also request a copy of our notice at any time. For more information about our privacy practices, contact
the person listed above.
INDIVIDUAL RIGHTS
In most cases, you have the right to look at or get a copy of health information
about you that we use to make decisions about you. If you request copies, we may charge you only normal photocopy fees. You
also have the right to receive a list of instances where we have disclosed health information about you for reasons other
than treatment, payment or related administrative purposes and other than when you explicitly authorized it. If you believe
that information in your record is incorrect or if important information is missing, you have the right to request that we
correct the existing information or add the missing information.
COMPLAINTS
If you are concerned that we have violated your privacy rights, or you disagree
with a decision we made about access to your records, you may contact Teton Nuclear Medicine. You also may send a written
complaint to the U.S. Department of Health and Human Services.
OUR
LEGAL DUTY
We are required by law to protect the privacy
of your information, provide this notice about our information practices, follow the information practices that are described
in this notice, and seek your acknowledgement of receipt of this notice.
If you would like us to release your medical information to anyone other than your Physician, you must list
them below.
______________________________________________________________
______________________________________________________________
______________________________________________________________
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I, _________________________, have been informed of this office's Notice
of Privacy Practices.
__________________________________,
____________
(Signature)
(Date)
