This notice describes how medical information about you may be used and disclosed and how you can get access to
Federal privacy laws permit me to make use and disclosures of your health information for treatment, payment and
health care operations. Protected health information is what I obtain in providing you with services. Such information
may include documenting symptoms, examination and test results; and diagnosis, treatment, and applying for further
care or treatment. It also includes billing documents for services. An example of using your health information for
treatment purposes is: During your treatment I consult another specialist. I share the information with the specialist and
get feedback. An example of using your health information for payment purposes is: Through my billing service I
request payment from your health insurance company. If that company requests information about your medical care, I
will provide information about you and the care given. An example of using your information for health care operations
is: From my insurer or other business associates I obtain services, such as quality assessment, quality improvement,
outcome evaluation, protocol and clinical guideline development, training programs, credentialing, medical review,
legal issues, and insurance. I will share information about you with the insurer or other business associates, as
necessary, to obtain these services.
YOUR HEALTH INFORMATION RIGHTS : The health and billing records I maintain are the physical property of the
office. However, the information in them belongs to you. You have a right to:
-Request a restriction on certain uses and disclosures of your health information. (I will comply.)
-Obtain a paper copy of the current Notice of Privacy Practices for Protected Health Information (this “Notice”).
-Request that you be allowed to inspect and copy your record.
-Appeal a denial of access to your protected health information, except in certain circumstances.
-Request that I amend your health care record to correct incomplete or incorrect information. I may deny your request
if you ask me to amend information that I did not create, unless the person or entity that created the information, (a), is
no longer available to make the amendment; (b), is not part of the health information kept by or for the office; (c), is not
part of the information you would be permitted to inspect or copy; or (d), is accurate and complete. If I deny your
request I will tell you why. I can also submit a statement of disagreement, maintained with your records.
-Request, by delivering the request in writing to my office, that I communicate your health information by alternative
means or at an alternative location;
-Obtain an accounting of disclosures of your health information, as required by law. An accounting will not include
uses and disclosures of information for treatment, payment and operations; disclosures or uses made to you or made
at your request; uses or disclosures made per your signed authorization; uses or disclosures made in a facility
directory or to family members or friends relevant to that person’s involvement in your care or payment for such care;
or, uses or disclosures to notify family or others responsible for your care or your location, condition, or your death.
-Revoke authorizations that you made previously to use or disclose information by delivering a written revocation to out
office, except to the extent information or action has already been taken.
If you want to exercise any of these rights, contact me at 1325 Eighteenth St NW #209, Washington DC 20036 (Tel
202.296.5877) in person or in writing, during regular business hours. I will tell you the steps necessary to exercise your
I must maintain the privacy of your health information, as required by law. I must provide you with a notice about my
duties and privacy practices about the information I collect and maintain. I must also abide by the terms of this Notice.
Further, I have to notify you if we cannot accommodate a requested restriction or request. I have to accommodate
reasonable requests regarding methods to communicate health information with you.
I reserve the right to amend, change or eliminate provisions in my privacy practices. I can enact new provisions about
the protected health information I obtain. If my information practices change I will amend my Notice. You are entitled to
a copy of the revised Notice by requesting it or by picking it up at the office.
TO REQUEST INFORMATION OR FILE A COMPLAINT
If you have questions, want additional information, or want to report a problem concerning the handling of your
information, please contact me at 202.296.5877.
As well, if you believe your rights have been violated, you may file a written complaint at the office by delivering a copy
to me. You may also file a complaint by mailing it to the Secretary of Health and Human Services, US. Government,
Washington DC 20052.
I cannot, and I will not, require you to waive the right to file a complaint with the Secretary of Health and Human Services
(HHS) as a condition of receiving treatment from me. I cannot, and I will not, retaliate against you for filing a complaint
with the Secretary of Health and Human Services.
OTHER DISCLOSURES AND USES: Communication with Family: I may disclose to a family member, relative, close
friend or any other person you identify, health information relevant to that person’s involvement in your care or its
payment (if you do not object or in an emergency).
Notification : Unless you object we may use or disclose your protected health information to notify, or help notify, a
family member, personal representative, or other person responsible for your care, about your location, and about
your condition at death.
Research : I may disclose information to researchers when their research is approved by an Institutional Review Board
that reviewed the proposal and established protocols to ensure the privacy of your protected health information.
Disaster Relief : I may use and disclose your protected health information to help in disaster relief.
Organ Procurement Organizations : Consistent with law, I may disclose your protected health information to organ
procurement organizations or other entities that procure, bank or transplant organs for tissue donation and
Food and Drug Administration (FDA):I may disclose to the FDA your protected health information about adverse
events involving food, supplements, products and defects, or post-marketing surveillance information to enable
product recalls, repairs or replacements.
Workers Compensation: If you are seeking compensation, I may disclose your protected health information as
necessary to comply with laws relating to Workers Compensation.
Public Health : As authorized by law, I may disclose your protected health information to public health or legal
authorities preventing or controlling disease, injury or disability; report reactions to medications or problems with
products; notify people of recalls; or notify a person who may have been exposed to a disease or who is at risk for
Abuse and Neglect: I may disclose protected health information to public authorities as allowed by law to report abuse
Employers : I may disclose health information about you to your employer. That is, if I provide health care services to
you at the request of your employer, and the health care services are provided either to evaluate medical surveillance
of the workplace, or to evaluate if you have a work-related illness or injury. In such cases I will give you written notice of
release of information to your employer. I will disclose other information to your employer only if you execute a specific
authorization for it.
Correctional Institution: If you are an inmate of a correctional institution, I may disclose to the institution or its agents
protected health information necessary for your health and the health and safety of others.
Law Enforcement: I may disclose your protected health information for law enforcement purposes as required by law,
such as by a court order, or in cases involving felony prosecution, or to the extent an individual is in the custody of law
Health Oversight: The law allows me to release your protected information to appropriate agencies or activities.
Judicial/Administrative Proceedings: I may disclose your health information during such proceeding as allowed or
required by law, with your authorization or by a proper court order.
Serious Threat : To avert serious threat to health or safety, I may disclose your protected health information,
consistent with applicable law, to prevent or lessen a serious, imminent threat to the health or safety of a person or the
For Specialized Governmental Functions: I may disclose your protected health information to such functions as
authorized by law. An example is to Armed Forces Personnel, for national security purposes.
Coroners, Medical Examiners, and Funeral Directors : I may release health information to a coroner or medical
examiner. This may be necessary, for example to identify a deceased person or to determine the cause of death. I
may also release health information about patients of Covered Entities to funeral directors necessary for them to carry
out their duties.
Other Uses : Other uses and disclosures, besides those in this Notice, will only be made as required by law or with your
written authorization. You may revoke the authorization previously provided in this Notice under “Your Health
Website: If I maintain a website that provides information about my entity, this Notice will be on the Website.
Effective Date: 04/31/03