Brunswick Princeton Family
Practice and Brunswick Princeton Industrial Medical Center H. Kline, D.O. privacy officer South Brunswick ( Monm Junct ) N.J.,4105 U.S. Route One,
Suite One, 08852, Telephone: (732) 329-8585, fax: (732) 329-5668, e-mail: firstname.lastname@example.org
Required by the Privacy Regulations Created as a Result of the Health Insurance
Portability and Accountability Act of 1996 (HIPAA)
OUR COMMITMENT TO YOUR PRIVACY
Our practice is dedicated to
maintaining the privacy of your individually identifiable health information
(IIHI). In conducting our business, we
will create records regarding you and the treatment and services we provide to
you. We are required by law to maintain
the confidentiality of health information that identifies you. We also are required by law to provide you
with this notice of our legal duties and the privacy practices that we maintain
in our practice concerning your IIHI. By
federal and state law, we must follow the terms of the notice of privacy
practices that we have in effect at the time.
We realize that these laws are
complicated, but we must provide you with the following important information:
How we may use and disclose your IIHI
Your privacy rights in your IIHI
Our obligations concerning the use and
disclosure of your IIHI
The terms of this notice apply to all
records containing your IIHI that are created or retained by our practice. 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 our practice has created or maintained in the past, and for any of your
records that 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 at all times, and you may request a
copy of our most current Notice at any time.
IF YOU HAVE QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT: Bradley H. Kline, D.O. in writing only
C. WE MAY USE AND DISCLOSE YOUR INDIVIDUALLY
IDENTIFIABLE HEALTH INFORMATION (IIHI) IN THE FOLLOWING WAYS
The following categories describe the
different ways in which we may use and disclose your IIHI.
Treatment. Our practice may use
your IIHI to treat you. For example, we
may ask you to have laboratory tests (such as blood or urine tests), and we may
use the results to help us reach a diagnosis.
We might use your IIHI in order to write a prescription for you, or we
might disclose your IIHI to a pharmacy when we order 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 IIHI in order to treat you or to assist others in your
treatment. Additionally, we may disclose
your IIHI to others who may assist in your care, such as your spouse, children
Finally, we may also disclose your IIHI
to other health care providers for purposes related to your treatment.
Payment. Our practice may use and
disclose your IIHI in order to bill and collect payment for the services and
items you may receive from us. For
example, we may contact your health insurer to certify that you are eligible
for benefits (and for what range of benefits), and we may provide your insurer
with details regarding your treatment to determine if your insurer will cover,
or pay for, your treatment. We also may
use and disclose your IIHI to obtain payment from third parties that may be responsible
for such costs, such as family members.
Also, we may use your IIHI to bill you directly for services and
items. We may disclose your IIHI to
other health care providers and entities to assist in their billing and
Health Care Operations. Our
practice may use and disclose your IIHI to operate our business. As examples of the ways in which we may use
and disclose your information for our operations, our practice may use your
IIHI to evaluate the quality of care you received from us, or to conduct
cost-management and business planning activities for our practice. We may disclose your IIHI to other health
care providers and entities to assist in their health care operations.
Appointment Reminders. Our
practice may use and disclose your IIHI to contact you and remind you of an
Options. Our practice may use and
disclose your IIHI to inform you of potential treatment options or
Health-Related Benefits and Services.
Our practice may use and disclose your IIHI to inform you of
health-related benefits or services that may be of interest to you.
Release of Information to Family/Friends. Our practice may release your IIHI 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 our office for treatment of a cold. In this example, the babysitter may have
access to you child’s medical information.
Disclosures Required By Law. Our
practice will use and disclose your IIHI when we are required to do so by
federal, state or local law.
D. USE AND DISCLOSURE OF YOUR IIHI IN CERTAIN
The following categories describe
unique scenarios in which we may use or disclose your identifiable health
Public Health Risks. Our practice
may disclose your IIHI to public health authorities that are authorized by law
to collect information for the purpose of:
maintaining vital records, such as
births and deaths
reporting child abuse or neglect
preventing or controlling disease,
injury or disability
notifying a person regarding potential
exposure to a communicable disease
notifying a person regarding a
potential risk for spreading or contracting a disease or condition
reporting reactions to drugs or
problems with products or devices
notifying individuals if a product or
device they may be using has been recalled
notifying appropriate government agency
(ies) and authority (ies) regarding the potential abuse or neglect of an adult
patient (including domestic violence); however, we will only disclose this
information if the patient agrees or we are required or authorized by law to
disclose this information
notifying your employer under limited
circumstances related primarily to workplace injury or illness or medical
Health Oversight Activities. Our
practice may disclose your IIHI to a health oversight agency for activities
authorized by law. Oversight activities
can include, for example, investigations, inspections, audits, surveys,
licensure and disciplinary actions; civil, administrative, and criminal
procedures or actions; or other activities necessary for the government to
monitor government programs, compliance with civil rights laws and the health
care system in general.
Lawsuits and Similar Proceedings.
Our practice may use and disclose your IIHI in response to a court or
administrative order, if you are involved in a lawsuit or similar proceeding. We also may disclose your IIHI in response to
a discovery request, subpoena, or other lawful process by another party
involved in the dispute, but only if we have made an effort to inform you of
the request or to obtain an order protecting the information the party has
Law Enforcement. We may release
IIHI if asked to do so by a law enforcement official:
Regarding a crime victim in certain
situations, if we are unable to obtain the person’s agreement
Concerning a death we believe has resulted
from criminal conduct
Regarding criminal conduct at our
In response to a warrant, summons,
court order, subpoena or similar legal process
To identify/locate a suspect, material
witness, fugitive or missing person
In an emergency, to report a crime
(including the location or victim(s) of the crime, or the description, identity
or location of the perpetrator)
Deceased Patients. Our practice
may release IIHI to a medical examiner or coroner to identify a deceased
individual or to identify the cause of death.
If necessary, we also may release information in order for funeral
directors to perform their jobs.
Organ and Tissue Donation. Our
practice may release your IIHI to organizations that handle organ, eye or
tissue procurement or transplantation, including organ donation banks, as
necessary to facilitate organ or tissue donation and transplantation if you are
an organ donor.
Research. Our practice may use
and disclose your IIHI for research purposes in certain limited circumstances. We will obtain your written authorization to
use your IIHI for research purposes except when an Internal Review Board
or Privacy Board has determined that the waiver of your authorization satisfies
the following: (i) the use or disclosure
involves no more than a minimal risk to your privacy based on the
following: (A) an adequate plan to
protect the identifiers from improper use and disclosure; (B) an adequate plan
to destroy the identifiers at the earliest opportunity consistent with the research
(unless there is a health or research justification for retaining the
identifiers or such retention is otherwise required by law); and (C) adequate
written assurances that the PHI will not be re-used or disclosed to any other
person or entity (except as required by law) for authorized oversight of the
research study, or for other research for which the use or disclosure would
otherwise be permitted; (ii) the research could not practicably be conducted
without the waiver; and (iii) the research could not practicably be conducted
without access to and use of the PHI.
Serious Threats to Health or Safety.
Our practice may use and disclose your IIHI when necessary to reduce or
prevent a serious threat to your health and safety or the health and safety of
another individual or the public. Under
these circumstances, we will only make disclosures to a person or organization
able to help prevent the threat.
9. Military. Our practice may disclose your IIHI if you
are a member of U.S. or foreign military forces (including veterans) and if
required by the appropriate authorities.
National Security. Our practice
may disclose your IIHI to federal officials for intelligence and national
security activities authorized by law.
We also may disclose your IIHI to federal officials in order to protect
the President, other officials or foreign heads of state, or to conduct
Inmates. Our practice may
disclose your IIHI to correctional institutions or law enforcement officials if
you are an inmate or under the custody of a law enforcement official. Disclosure for these purposes would be
necessary: (a) for the institution to provide health care services to you, (b)
for the safety and security of the institution, and/or (c) to protect your
health and safety or the health and safety of other individuals.
Workers’ Compensation. Our
practice may release your IIHI for workers’ compensation and similar programs.
YOUR RIGHTS REGARDING YOUR IIHI
You have the following rights regarding
the IIHI that we maintain about you:
Communications. You have the right to
request that our practice 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 [Bradley H. Kline, D.O. at place above by certified written mail only 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
Requesting Restrictions. You have
the right to request a restriction in our use or disclosure of your IIHI for
treatment, payment or health care operations.
Additionally, you have the right to request that we restrict our
disclosure of your IIHI 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. There may be a fee to you
for costs any costs incurred by us to comply with such requests. In order to request a restriction in our use
or disclosure of your IIHI, you must make your request in writing to Bradley H.
Kline, D.O. at place above by certified written mail only. Your request must
describe in a clear and concise fashion:
information you wish restricted;
you are requesting to limit our practice’s use, disclosure or both; and
whom you want the limits to apply.
Inspection and Copies. You have
the right to inspect and obtain a copy of the IIHI that may be used to make
decisions about you, including patient medical records and billing records, but
not including psychotherapy notes. You
must submit your request in writing to Bradley H. Kline, D.O. at place above by
certified written mail only in order to inspect and/or obtain a copy of your
IIHI. Our practice may charge a fee for
the costs of copying, mailing, labor and supplies associated with your request. Our practice may deny your request to inspect
and/or copy in certain limited circumstances; however, you may request a review
of our denial. Another licensed health care professional chosen by us will
3. Amendment. 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 in writing and submitted to Bradley H. Kline, D.O. at the address above
by certified mail You must provide us
with a reason that supports your request for amendment. Our practice will 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 is in our opinion: (a) accurate and
complete; (b) not part of the IIHI kept by or for the practice; (c) not part of
the IIHI which you would be permitted to inspect and copy; or (d) not created
by our practice, unless the individual or entity that created the information
is not available to amend the information.
Accounting of Disclosures. All of
our patients have the right to request an “accounting of disclosures.” An “accounting of disclosures” is a list of
certain non-routine disclosures our practice has made of your IIHI for
non-treatment, non-payment or non-operations purposes. Use of your IIHI as part of the routine
patient care in our practice is not required to be documented. For example, the doctor sharing information
with the nurse; or the billing department using
your information to file your insurance claim. In order to obtain an accounting of disclosures,
you must submit your request in writing
Bradley H. Kline, D.O. at the address above by certified mail All
requests for an “accounting of disclosures” must state a time period, which may
not be longer than six (6) years from the date of disclosure and may not
include dates before April 14, 2003. The
first list you request within a 12-month period is free of charge, but our
practice may charge you for additional lists within the same 12-month
period. Our practice 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. You may ask us to give you a
copy of this notice at any time. To
obtain a paper copy of this notice, contact
to Bradley H. Kline, D.O. at the
address above by certified mail. You may
be asked to reimburse our practice for any cost it incurs in order to comply
with your request
Right to File a Complaint. If you
believe your privacy rights have been violated, you may file a complaint with
our practice or with the Secretary of the Department of Health and Human
Services. To file a complaint with our
practice, contact Bradley H. Kline, D.O.
by certified mail. All complaints must
be submitted in writing. You will not be penalized for filing a complaint.
Right to Provide an Authorization for Other Uses and Disclosures. Our practice 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 IIHI
may be revoked at any time in writing. After you revoke your
authorization, we will no longer use or disclose your IIHI for the reasons
described in the authorization. Please
note, we are required to retain records of your care.
If You don't want any
element of your chart shared, you should let us know this so that we can put it
Again, if you have any questions
regarding this notice or our health information privacy policies, please
contact Bradley H. Kline, D.O. in writing only.