Notice of Privacy Practices

How we may use and disclose your health information

The following describes the ways we may use and disclose your protected health information, with an example of each. Not every permitted use or disclosure is listed, but every use or disclosure we make falls into one of these categories.

For treatment

We use your health information to provide you with medical care, and we share it with others who are treating you.

For example: a vein specialist in this practice reviews your duplex ultrasound results to plan your treatment, and we send a summary of your visit to the primary care doctor who referred you.

For payment

We use and disclose your health information so that the treatment you receive can be billed and paid for, by you, by an insurance company, or by another third party.

For example: we send your insurer details of the ultrasound findings and the procedure performed so they can decide whether the treatment is covered, and we may contact your insurer in advance to confirm coverage.

For health care operations

We use and disclose your health information to run this practice and to make sure our patients receive quality care.

For example: we review records to assess the quality of our treatments, to train staff, and for licensing, audit and accreditation purposes.

Other uses and disclosures we may make without your authorization

The law also permits or requires us to use or disclose your information in these situations:

• Appointment reminders, and information about treatment alternatives or health-related benefits and services that may interest you
• To a family member, friend or other person involved in your care or payment for your care, to the extent relevant and where you have not objected
• To notify someone of your location, general condition or death, including to disaster relief organisations
• When required by federal, state or local law
• For public health activities, such as reporting disease, injury, or problems with products and reactions to medications
• To report suspected abuse, neglect or domestic violence
• For health oversight activities, such as audits, investigations and inspections by government agencies
• In response to a court or administrative order, subpoena, warrant or other lawful process
• For law enforcement purposes permitted by law
• To coroners, medical examiners and funeral directors
• For organ, eye or tissue donation
• For research, where an institutional review board has approved the research and the privacy protections around it
• To prevent a serious and imminent threat to the health or safety of you or others
• For specialised government functions, including military, national security and protective services
• For workers compensation claims, as authorised by law
• To correctional institutions, if you are an inmate

Where another law, including New York State law, is stricter than HIPAA about a particular kind of information, we follow the stricter law.

[PLACEHOLDER: Your Privacy Officer should confirm this list matches this practice. Remove anything this practice does not do, and add any New York State specific limits that apply, for example to HIV related information, mental health records or substance use disorder records.]

Uses and disclosures that require your written authorization

We will not make the following uses or disclosures without your written authorization:

• Most uses and disclosures of psychotherapy notes, where we hold any
• Uses and disclosures for marketing purposes
• Disclosures that are a sale of your protected health information

Any other use or disclosure not described in this notice will be made only with your written authorization.

If you give us an authorization, you may revoke it in writing at any time. The revocation will stop any further use or disclosure for the purposes you authorized, except to the extent we have already acted in reliance on it.

Your rights regarding your health information

You have the following rights. To exercise any of them, please make your request in writing to our Privacy Officer at the address at the bottom of this notice.

The right to ask for restrictions

You may ask us to restrict how we use or disclose your health information for treatment, payment or health care operations, or to someone involved in your care.

We are not required to agree to your request, except in one case: if you pay for a service in full, out of pocket, and ask us not to share information about that service with your health plan, we must agree.

The right to confidential communications

You may ask us to contact you in a particular way, or at a particular address or number. For example, you may ask that we call only your mobile, or write to you at a work address. We will accommodate reasonable requests.

The right to see and copy your records

You have the right to inspect and get a copy of the health information we use to make decisions about your care, including an electronic copy where we hold it electronically. We may charge a reasonable, cost-based fee for copies.

In limited circumstances we may deny a request, and you may ask for that denial to be reviewed.

The right to ask for a correction

If you believe information in your record is incorrect or incomplete, you may ask us to amend it. We may deny your request if the information was not created by us, is not part of the records we keep, is not information you would be permitted to inspect, or is accurate and complete. If we deny your request, we will tell you why in writing and you may file a statement of disagreement.

The right to an accounting of disclosures

You may ask for a list of the disclosures we have made of your health information. The list does not have to include disclosures for treatment, payment or health care operations, disclosures you authorized, or certain other disclosures the law excludes.

The right to a paper copy of this notice

You may ask for a paper copy of this notice at any time, even if you agreed to receive it electronically. Ask at the front desk and we will give you one.

Our duties

• We are required by law to maintain the privacy of your protected health information.
• We are required to give you notice of our legal duties and privacy practices regarding your health information.
• We are required to notify you if a breach of your unsecured protected health information occurs.
• We are required to follow the terms of the notice that is currently in effect.

We reserve the right to change this notice, and to make the revised notice apply to health information we already hold as well as to information we create or receive in the future. If we make a material change, we will post the revised notice in our office and on this website, and you may ask for a copy at any visit.

How to complain

If you believe your privacy rights have been violated, you may complain to us, or to the Secretary of the U.S. Department of Health and Human Services. Both are free.

To complain to us, write to our Privacy Officer at the address below, describing what happened.

To complain to the federal government, write to the Office for Civil Rights, U.S. Department of Health and Human Services, 200 Independence Avenue SW, Washington DC 20201, call 1-877-696-6775, or file online at hhs.gov/ocr/privacy/hipaa/complaints.

We will not retaliate against you in any way for filing a complaint.

Who to contact

• Privacy Officer: [NAME OR TITLE]
• Telephone: [PRIVACY OFFICER TELEPHONE NUMBER]
• Address: Renew Vein Center, 515 Madison Avenue, New York, NY 10022

If you have any question about this notice, or would like more information about our privacy practices, please contact our Privacy Officer.

[PLACEHOLDER: HIPAA requires a name or title and a telephone number here. A title such as "Privacy Officer" is sufficient; a personal name is not required.]