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Notice Of Privacy Practices
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION
ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS
TO THIS INFORMATION.
PLEASE REVIEW IT CAREFULLY.
THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain
the privacy of your health information. We are also required to
give you this notice about out privacy practices, our legal
duties, and your rights concerning your health information. We
also must follow the privacy practice that are described in this
notice while it is in effect. This Notice takes effect
immediately and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the
terms of this notice at any time. Provided such changes are
permitted applicable law. We reserve the right to make changes
in our privacy practices and the new terms of our notice
effective for all health information that we maintain, including
health information we created or received before we made the
changes. Before we make a significant change in our privacy
practices, we will change this notice, and make the new notice
available upon request.
You may request a copy of our notice at any time. For more
information about our privacy practices, or for additional
copies of this notice, please contact us using the information
listed at the end of this notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment,
payment, and healthcare operations. For example:
Treatment: We may use and disclose your health
information to a physician or other health care provider
providing treatment to you.
Payment: We may use and disclose your health
information to obtain payment for services we provide to you.
Healthcare: We may use and disclose your health
information in connection with our healthcare operations.
Healthcare operations include quality assessment and improved
activities, reviewing the competence or qualifications of
healthcare professionals, evaluating practitioner and provider
performance, conducting training programs, accreditation,
certification, licensing or credentialing activities.
Your Authorization: In addition to our use of your
health information for treatment, payment or healthcare, you may
give us written authorization to use your health information or
to disclose it to anyone for any purpose. If you give us an
authorization, you may revoke it in writing at anytime. Your
revocation will not affect any use of disclosures permitted by
your authorization while it was in effect. Unless you give us
written authorization, we cannot use or disclose your health
information for any reason except those described in this
notice.
To Your Family and Friends: We must disclose your
health information to you, as described in the Patient Rights
section of this Notice. We may disclose your health,
information to any family member, friend or other person to the
extent necessary to help you with your healthcare or-with
payment for your health care, but only if you agree that we may
do so.
Persons Involved In Care: We may use or disclose
health information to notify or assist in the notification of
(including identifying or locating) a family member, your
personal representative or another person responsible for your
care, of your location, your general condition, or death. If
you are present, then prior to use or disclosure of your health
information, we will provide you with an opportunity to object
to such uses or disclosures. In the event of your incapacity or
emergency circumstances, we will disclose health inform based on
determination using our professional judgement disclosing only
health information that is directly relevant to the persons
involvement in your healthcare. We will also use our
professional judgement and our experience with common practice
to make reasonable inferences of your best interest in allowing
a person to pickup filled prescriptions, medical supplies,
x-rays or other similar forms of health information.
Marketing health-Related Services: We will not use
your health information for marketing communications without
your written authorization.
Required by Law: We may use or disclose your health
information when we are required to do so by law.
Abuse or Neglect: We may disclose your health
information to appropriate authorities if we reasonably believe
that you are possible victim of abuse, neglect, or domestic
violence or the possible victim of other crimes. We may
disclose your health information to avert a serious threat to
your health or safety or the health or safety of others.
National Security: We may disclose to military
authorities the health information of Armed Forces persons under
certain circumstances. We may disclose to authorized federal
officials health information required for lawful intelligence,
counterintelligence, and other national security activities. We
may disclose to correctional institution or law enforcement
official having lawful custody of protected health information
of inmate or patient under certain circumstances.
Appointment Reminders: We may use or disclose your
health information to provide you with appointment reminders
(such as voicemail messages, postcards, or letters).
PATIENT RIGHTS
Access: You have the right to look at or get copies of
your health information, with limited exceptions. You may
request that we provide copies in a format other than
photocopies. We will use the format that you request unless we
cannot practicably do so. (You must make a request in writing
to obtain access to your health information. You may obtain a
form to request access by using the contact information listed
at the end of this Notice. We will charge you a reasonable
cost-based fee for expenses such as copies and staff time. You
may also request access by sending us a letter to the address at
the end of this Notice. If you request copies, we will charge
you a reasonable amount not to exceed $0.75 for each page to
copy your health information, and postage if you want the copies
mailed to you. If you request an alternative format, we will
charge a cost-based fee for providing your health information in
that format. If you prefer, we will prepare a summary or an
explanation of your health information for a fee. Contact us
using the information listed at the end of this notice for a
full explanation of our fee structure.)
Disclosure Accounting: You have the right to receive
a list of instances in which we or our business associates
disclosed your health information for purposes, other than
treatment, payment, healthcare operations and certain other
activities, for the last 6 years, but not before April 14,
2003. If you request this accounting more than once in a twelve
month period, we may charge you a reasonable cost-based fee for
responding to these additional requests.
Restriction: You have the right to request that we place
additional restrictions on our use or disclosure of your health
information. We are not required to agree to those additional
restrictions, but if we do. We will abide by our agreement
(except in an emergency).
Alternative Communication: You have the right to
request that we communicate with you about your health
information by alternative means or to alternative locations.
(You must make your request in writing.) Your request must
specify the alternative means or location, and provide
satisfactory explanation how payments will be handled under the
alternative means or location you request.
Amendment: You have the right to request that we
amend information. (Your request must be in writing, and it
must explain why the information should be amended.) We may
deny your request under certain circumstances.
Electronic Notice: If you receive this notice on our
website, or by electronic mail (e-mail), you are entitled to
receive this Notice in written form.
QUESTIONS AND COMPLAINTS
If you want more information about out privacy practices or have
questions or concerns, please contact us.
If you are concerned that we may have violated your privacy
rights, or you disagree with a decision we made about access to
your health information or in response to a request you made to
amend or restrict the use or disclosure of your health
information or to have us communicate with you by alternative
means or at alternative locations, you may complain to us using
the contact information listed at the end of this Notice. You
also may submit a written complaint to the U.S. Department of
Health and Human Services. We will provide you with the address
to file your complaint with the U.S. Department of Health and
Human Services upon your request.
We support your right to the privacy of your health
information. We will not retaliate in any way if you choose to
file a complaint with us or with the U.S. Department of Health
and Human Services.
| Contact Officer: |
Dr.
Michael Grassi |
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| Telephone: |
(585) 424-1111 |
(585) 227-3400
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| Fax: |
(585) 424-1110 |
(585) 227-2414
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| Address: |
369
White Spruce Blvd.
Rochester, NY 14623 |
Suite 202
2081 Ridge Road W.
Rochester, NY 14626 |
| Web
Page: |
www.GrassiAndGrassi.com |
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