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HIPAA 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.
OUR COMMITMENT TO YOUR PRIVACY
We understand that information about you and your health care is personal. We create a record of the care and services
you receive from MY DR NOW and are committed to protecting health information about you. We are required by law to
1) Make sure health information that identifies you is kept private; 2) Give you this notice of our privacy practices, and 3)
Follow the terms of the notice that is currently in effect.
ROUTINE USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION
The following categories describe the different ways in which we may use and disclose your protected health information
Treatment. We may use your PHI to treat you (i.e., laboratory tests, when we order or write a prescription for you). Many
of the people who work for our practice – including, but not limited to, our doctors and nurses – may use or disclose your
PHI in order to treat you or to assist others in your treatment. Additionally, we may disclose your PHI to others outside
MDN who are involved in your medical care.
Payment. We may use and disclose your PHI to you, an insurance company, or a third party in order to bill and collect
payment for the services you receive from us.
Health Care Operations. We may use and disclose your PHI to operate our business, i.e. we may use and disclose
your information for our operations, our practice may use your PHI to evaluate the quality of care you received from us,
or to conduct cost-management and business planning activities for our practice. There are some services we may
provide through our business associates.
Appointment Reminders. We may use and disclose your PHI to contact you and remind you of an appointment.
Treatment Options. We may use and disclose your PHI to inform you of potential treatment options or alternatives.
Health-Related Benefits and Services. Our practice may use and disclose your PHI to inform you of health-related
benefits or services.
Release of Information to Family/Friends. Our practice may release your PHI to a friend or family member that is
involved in your care or who assists in taking care of you. For example, a parent or guardian may ask that a babysitter
take their child to the pediatrician’s office for treatment of a cold. In this example, the babysitter may have access to this
child’s medical information.
YOUR RIGHTS REGARDING YOUR PHI
You have the following rights regarding the PHI that we maintain about you:
Confidential Communications. You have the right to request that we communicate with you about your health and
related issues in a particular manner or at a certain location. For instance, you may ask that we contact you at home,
rather than work. In order to request a type of confidential communication, you must make a written request to the front
office, specifying the requested method of contact, or the location where you wish to be contacted. Our practice will
accommodate reasonable requests. You do not need to give a reason for your request.
You have the right to request a restriction in our use or disclosure of your PHI for treatment,
payment, or health care operations. Additionally, you have the right to request that we restrict our disclosure of your PHI
to only certain individuals involved in your care or the payment for your care, such as family members and friends. We
are not required to agree to your request; however, if we do agree, we are bound by our agreement except when
otherwise required by law, in emergencies, or when the information is necessary to treat you. To request a restriction,
you must make your request in writing to the Medical Records Department. Your request must describe in a clear and
concise fashion 1) the information you wish restricted; 2) whether you are requesting to limit our practice’s use,
disclosure or both; and 3) to whom you want the limits to apply. You may submit your request to
Inspection and Copies.
You have the right to inspect and obtain a copy of the PHI, including patient medical records
and billing records, but not including psychotherapy notes. You must submit your request in writing to the Medical
Records Department in order to inspect and/or obtain a copy of your PHI. We may charge a fee for the costs of copying,
mailing, and supplies associated with your request. We try to accommodate all reasonable requests; however, if we deny
your request to inspect and/or copy, you may request a review of our denial. You may submit requests to
You may ask us to amend your health information if you believe it is incorrect or incomplete, and you may
request an amendment for as long as the information is kept by or for our practice. To request an amendment, your
request must be made on our form Request to Amend Medical Records
and submitted to the Medical Records
Department. You must provide us with a reason that supports your request for amendment. We may deny your request if
you fail to submit your request (and the reason supporting your request) in writing. Also, we may deny your request if you
ask us to amend information that was not created by us or is not part of the medical information maintained by us, or if
the information is accurate and complete. If we deny your request, you can appeal our decision, in writing. You can
contact the Medical Records Department by email at MedicalRecords@MYDRNOW.com
to request and submit a
Request to Amend Medical Records form.
Accounting of Disclosures.
All of our patients have the right to request an accounting of disclosures made. This
accounting will not include routine disclosures for treatment, payment, or health care operations purposes. In order to
obtain an accounting of disclosures, you must submit your request in writing to the Medical Records Department by
. The first list you request within a 12-month period is free of charge. We
may charge you for additional lists within the same 12-month period. We will notify you of the costs involved with
additional requests, and you may withdraw your request before you incur any costs.
Right to a Paper Copy of This Notice.
You are entitled to receive a paper copy of our notice of privacy practices. To
obtain a paper copy of this notice, contact the Medical Records Department at MedicalRecords@MYDRNOW.com
USE AND DISCLOSURE OF YOUR PHI IN CERTAIN SPECIAL CIRCUMSTANCES
We may use and disclose your PHI without your written permission when we are required to do so by federal, state, or
local law, such as for law enforcement purposes, suspected abuse or neglect reporting, health oversights or audits,
funeral arrangements, organ donation, public health purposes, or in an emergency.
OTHER USES OF HEALTH INFORMATION
We will obtain your written authorization for uses and disclosures that are not identified by this notice or permitted by
applicable law. Any authorization you provide to us regarding the use and disclosure of your PHI may be revoked at any
time in writing. After you revoke your authorization, we will no longer use or disclose your PHI for the reasons described
in the authorization. Please note, we are required to retain records of your care. You may revoke your authorization to
disclose your PHI by contacting the Medical Records Department at MedicalRecords@MYDRNOW.com
If you believe your privacy rights have been violated, you may file a complaint with our Administrative team by email at
MINORS AND PERSONS WITH GUARDIANS
Minors and certain disabled adults are entitled to the privacy protection for their health information. Because by law, they
cannot make health care decisions for themselves, a parent or guardian can make medical decisions on their behalf.
Therefore, parents or guardians can authorize the use and release of PHI and also hold all rights listed in this notice.
Under certain situations defined by law, minors can make independent healthcare decisions without parent or guardian
knowledge or consent. In those situations, the minor may hold all rights listed in this notice. If the minor chooses to
inform the parent or guardian, then all privacy rights regarding PHI may transfer to the parent or guardian. There are also
certain situations where access, use or release of a minor’s PHI may occur without the consent of the parent or
guardian, i.e. when the health or safety of the minor is in danger and PHI is necessary to protect the minor.
We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this
notice will be effective for all of your records that we have created or maintained in the past, and for any we may
create or maintain in the future. Our practice will post a copy of our current Notice in our offices in a visible
location, and you may request a copy of our most current Notice at any time.