Effective Date: October 1, 2002
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.
YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE, PLEASE CONTACT DR. SAHOURI.
Your medical information
is personal. We are committed to protecting your medical information. We
create a record of the care and services you receive at this office. We
need this record to provide you with quality care and to comply with
certain legal requirements. This Notice applies to all of the records of
your care generated by this office whether made by your personal
physician or one of the office's employees.
This Notice will tell you
about the ways in which we may use and disclose your medical
information. This Notice will also describe your rights and certain
obligations we have regarding the use and disclosure of your medical
This office is required by
(1) make sure that medical
information that identifies you is kept private;
(2) give you this Notice of
our legal duties and privacy practices with respect to medical
information about you; and
(3) follow the terms of the
Notice that is currently in effect.
How this Office May Use and Disclose Your Medical
The following describes
the different ways that your medical information may be used or
disclosed by this office. For clarification we have included some
examples. Not every possible use or disclosure is specifically
mentioned. However, all of the ways we are permitted to use and disclose
your medical information will fit within one of these general
We will use medical information about you to provide you with medical
treatment and services. We may disclose medical information about you to
doctors, nurses, technicians and other office personnel who are involved
in providing you medical treatment.
We may use and disclose medical information about you so that the
treatment and services you receive at this office may be billed to and
payment may be collected from you, an insurance company or a third
party. For example, we may need to give your health plan information
about treatment you received here so your health plan will pay us or
reimburse you for the treatment. We may also tell your health plan about
a treatment you are going to receive to obtain prior approval or to
determine whether your plan will cover the treatment.
We may use and disclose medical information about you for office
operations. These uses and disclosures are necessary to run our office
and make sure that all of our patients receive quality care. For
example, we may use medical information to review our treatment and
services and to evaluate the performance of our staff in caring for you.
We may also combine medical information about many of our patients to
decide what additional services the office should offer, what services
are not needed, and whether certain new treatments are effective. We may
also disclose information to doctors, nurses, technicians, and other
office personnel for review and learning purposes. We may remove
information that identifies you from this set of medical information so
others may use it to study health care and health care delivery without
learning the identity of the specific patients.
We may use and disclose medical information to contact you as a reminder
that you have an appointment for treatment or medical care at this
We may use and disclose medical information to tell you about or
recommend possible treatment options or alternatives that may be of
interest to you.
Health-Related Benefits and Services.
We may use and disclose medical information to tell you about
health-related benefits or services that may be of interest to you.
Under certain circumstances, we may use and disclose medical information
about you for research purposes. For example, a research project may
involve comparing the health and recovery of all patients who received
one medication to those who received another for the same condition.
By Law. We
will disclose medical information about you when required to do so by
federal, state or local law. For example, disclosure may be required by
Workers' Compensation statutes and various public health statutes in
connection with required reporting of certain diseases, child abuse and
neglect, domestic violence, adverse drug reactions, etc.
To Avert a
Serious Threat to Health or Safety.
We may use and disclose medical information about you when necessary to
prevent a serious threat to your health and safety or the health and
safety of the public or another person. Any disclosure, however, would
only be to someone able to help prevent the threat.
We may disclose medical information to a governmental or other oversight
agency for activities authorized by law. For example, disclosures of
your medical information may be made in connection with audits,
investigations, inspections, and licensure renewals, etc.
If you are involved in a lawsuit or a dispute, we may use your medical
information to defend the office or to respond to a court order.
We may release medical information about you if required by law when
asked to do so by a law enforcement official.
We may release medical information to a coroner or medical examiner to
identify a deceased person or determine the cause of death.
Your Rights Regarding Your Medical Information:
You have the following
rights regarding the medical information this office maintains about
Inspect and Copy.
You have the right to inspect and copy your medical information with the
exception of any psychotherapy notes.
To inspect and copy your
medical information, you must submit your request in writing to Dr.
Sahouri. If you request a copy of the information, we may
charge a fee for the costs of copying, mailing or other supplies
associated with your request.
We may deny your request
to inspect and copy in certain very limited circumstances. If you are
denied access to your medical information, you may request that the
denial be reviewed. For information regarding such a review,
contact Dr. Sahouri.
you feel that medical information we have about you is incorrect or
incomplete, you may ask us to amend the information. You have the right
to request an amendment for as long as the information is kept by this
To request an amendment,
your request must be made in writing and submitted to Dr. Sahouri.
In addition, you must provide a reason that supports your request.
We may deny your request
for an amendment if it is not in writing or does not include a reason to
support the request. In addition, we may deny your request if you ask us
to amend information that:
(a) Was not created by us;
(b) Is not part of the
medical information kept by this office;
(c) Is not part of the
information which you would be permitted to inspect and copy; or
(d) Is accurate and complete.
Right to an
Accounting of Disclosures.
You have the right to request an "accounting of disclosures." This is a
list of the disclosures this office has made of your medical
To request this accounting
of disclosures, you must submit your request in writing to Dr.
Sahouri. Your request must state a time period which may not be
longer than six years and may not include dates before February 26,
You have the right to request a restriction or limitation on the use or
disclosure we make of your medical information. We are not required to
agree to your request for a restriction. If we do agree, we will comply
with your request unless the information is needed to provide you
To request restrictions,
you must make your request in writing to Dr. Sahouri.
Request Confidential Communications.
You have the right to request that we communicate with you only in a
certain manner. For example, you can ask that we only contact you at
work or by mail.
To request confidential
communications, you must make your request in writing to Dr. Sahouri.
We will accommodate all reasonable requests.
Right to a
Paper Copy of This Notice.
You have the right to a paper copy of this Notice. Even if you have
agreed to receive this Notice electronically, you are still entitled to
a paper copy of this Notice.
To obtain a paper copy of
this Notice, contact Dr. Sahouri or his staff,
print this page, or you may download a PDF copy by clicking
Revisions to This Notice
We reserve the right to
revise this Notice. Any revised Notice will be effective for medical
information we already have about you as well as any information we
receive in the future. We will post a copy of any revised Notice in this
office. Any revised Notice will contain on the first page, in the
top right-hand corner, the effective date. In addition, each time you
visit the office we will offer you a copy of the current Notice in
If you believe your
privacy rights have been violated, you may file a complaint with this
office or with the Secretary of the Department of Health and Human
To file a
compliant with this office, contact Dr. Sahouri at
All complaints must be submitted in writing.
THIS OFFICE WILL NOT
PENALIZE YOU IN ANY WAY FOR FILING A COMPLAINT.
Other Uses of Medical Information
Other uses and disclosures
of your medical information not covered by this Notice of Privacy
Practices will be made only with your written authorization. If you
provide us such an authorization in writing to use or disclose medical
information about you, you may revoke that authorization, in writing, at
any time. If you revoke your authorization, we will no longer use or
disclose medical information about you for the reasons covered by your