MEMPHIS OBSTETRICS & GYNECOLOGICAL ASSOCIATION, P.C. NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION MAY BE USED AND DISCLOSED AND HOW TO OBTAIN THIS INFORMATION. PLEASE REVIEW CAREFULLY. YOU HAVE THE RIGHT TO OBTAIN A COPY OF THIS NOTICE UPON REQUEST.
Patient Health Information
Under federal law, your patient health information is protected and confidential. Patient health information includes information about your symptoms, test results, diagnosis, treatment, and related medical information. Your health information also includes payment, billing, and insurance information.
How We Use Your Patient Health Information
We are permitted by law to use and disclose patient health information for treatment, payment, and healthcare operations.
Examples of Treatment, Payment, and Health Care Operations
Treatment: We will use and disclose your health information to provide medical treatment or services. For example, nurses, physicians, and other members of your treatment team will record information in your record and use it to determine the most appropriate course of care. We may also disclose the information to other healthcare providers who are participating in your treatment, to pharmacists who are filling your prescriptions, and to family members who are helping with your care.
Payment: We will use and disclose your health information for payment purposes. For example, we may need to obtain authorization from your insurance company before providing certain types of treatment. We will submit bills and maintain records of payment from your health plan.
Healthcare Operations: We will use and disclose your health information to conduct our standard internal operations, including proper administration of records, evaluation of the quality of treatment, and to assess the care and outcome of your case and others similar to it.
We may use your information to contact you with appointment reminders. We may also contact you to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Other Uses and Disclosures
We may use and disclose identifiable health information about you for other reasons, even without your consent.
Subject to certain requirements, we are permitted to give out health information about you for the following purposes:
Required by Law: We are required by law to report gunshot wounds, suspected abuse or neglect, or similar injuries and
Public Health Activities: As required by law, we may disclose vital statistics, diseases, information related to recalls of
dangerous products, and similar information to public health authorities.
Health Oversight: We may be required to disclose information to assist in investigations and audits, eligibility for
government programs, and similar activities.
Judicial and Administrative Proceedings: We may disclose information in response to an appropriate subpoena or court
Law Enforcement Purposes: Subject to certain restrictions, we may disclose information required by law enforcement
Deaths: We may report information regarding deaths to coroners, medical examiners, funeral directors, and organ
Serious Threat to Health or Safety: We may use and disclose information when necessary to prevent serious threat to
the health and safety of you, another person, or the public.
Military and Special Government Functions: If you are a member of the armed forces, we may release information as
required by military command authorities. We may also disclose information to correctional institutions or for national
Research: We may use or disclose information for approved medical research.
Workers Compensation: We may release information about you for workers compensation or similar programs
providing benefits for work-related injuries or illnesses.
In any other situation, we will require written authorization before using or disclosing any protected health information.
If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop any future
uses and disclosures. Revocation requests must be made in writing and submitted to the clinic’s Privacy Officer.
You have the following rights with regard to your health information. Please contact our office to obtain the appropriate
form for exercising these rights
Request Restrictions: You may request restrictions on certain uses and disclosures of your health information. We are
not required to agree to such restrictions, but if we do agree, we must abide by them.
Confidential Communications: You may ask us to communicate confidentially by, for example, sending notices to a
special address or not calling with appointment reminders.
Inspect and Obtain Copies: In most cases, you have the right to look at or obtain a copy of your health information. There may be a charge for the copies.
Amend Information: If you believe that information in your record is incorrect or that important information is missing,
you have the right to request that we correct the existing information or add the missing information. We are not
required to agree to such amendment, but must let you know our reasons.
Accounting of Disclosures: You may request a list of instances where we have disclosed health information about you
for reasons other than treatment, payment, or health care operations.
Our Legal Duty
We are required by law to protect and maintain the privacy of your health information, to provide this Notice about our legal duties and privacy practices regarding protected health information, and to abide by the terms of the Notice currently in effect. Upon request, you may receive a copy of this notice.
Changes in Privacy Practices
We may change our policies at any time. Before we make a significant change in our policies, we will change our Notice
and post the new Notice in the waiting area and each examination room. You may also request a copy of our Notice at
any time. For more information about our privacy practices, contact our Privacy Officer.
If you are concerned that we have violated your privacy rights, or if you disagree with a decision we have made about
your records, please contact our Privacy Officer. You may also send a written complaint to the U.S. Department of
Health and Human Services. The Privacy Officer will provide you with the appropriate address upon request. You will
not be penalized in any way for filing a complaint.
Contact Person / Privacy Officer
If you have any questions, complaints, or requests, please contact:
8110 N Brother Blvd, Ste.200
Bartlett, TN 38133
(901) 202-6122 or firstname.lastname@example.org
6215 Humphreys Blvd # 401
Memphis, TN 38120
(901) 767-8442, ext 2020 or email@example.com
This Notice became effective April 14, 2003, and was revised on January 14, 2020.